Incident directory

2007 - Atherstone on Stour

02/11/2007

Country:

UK

  • Building Fires

Severity:

Fatal

Description

Date of event

2nd November 2007.         

Time of event

Approximately 17:35 HRS (INITIAL CALL) To Gloucestershire Fire and Rescue Service (GFRS).

Name of premises

Whealmoor Atherstone Ltd, Hanger 1.

Location

Atherstone Industrial Estate, Shipston Road, Atherstone on Stour, Warwickshire.

Service area

Warwickshire FRS.

Nature of incident

Fire

Property type

Industrial Warehouse approximately 150 m x 69 m.

Premises use

Food processing.

Construction type and materials

Steel frame and sandwich panel over a concrete base.

Occupancy

Commercial use.

Fire source and location of fire

Unknown ignition source but suspected deliberate, involving packaging materials on part of the first floor storage area.

Synopsis

Brief Synopsis

Warwickshire Fire and Rescue Service (WFRS) were called to attend a fire at a food processing plant on the 2nd November 2007 at approximately 17:37. 2 pumps were initially mobilised to the incident at approximately 17:40 and arrived at approximately 17:52 and 17:54. 2 firefighters (initial team designated by callsign Red 1*) in Breathing Apparatus (BA) entered into the warehouse to try and locate the fire with extended hose reels (x2). When they could not locate the fire due to the hose reel not being long enough they withdrew from the fire compartment to the corridor and waited for the hosereel to be further extended by another 2 lengths. A short time later (Red 1) withdrew due to running low on air. Doors within the corridor had been held/propped open (WFRS & FBU Unknown date).

A further team of 2 BA (initial team designated by callsign Red 2) entered at approximately 18:15 with the further extended hose reel (x4) and a Thermal Imaging Camera (TIC) whereby they attempted to locate and fight the fire. Red 1 and Red 2 exchanged information within the corridor area. Red 2 advanced into what they perceived as the fire compartment with gas cooling techniques which, the team were concerned about, ‘gas cooling sprays not being effective’ (WFRS, Unknown date). Red 2 had described a point where it was notably hotter and they could not hear or feel any water coming down when they tried gas cooling with pulse sprays. They could not locate the seat of the fire and due to the deteriorating conditions created by heat, visibility and steam produced, they withdrew.

At approximately 18:28 a make pumps 3 message was sent. Red 2 were observed to be exhibiting signs of heat stress after exiting at approximately 18:30. A third BA team made up from Red 1 original wearers, recommitted as second team designated by callsign Red 1 (BA3 and BA team 3 in reports) was sent into the building to locate and fight the fire using the original extended (x4) hosereel. The third BA team (Red 1) could not locate the fire, the team leader became partially entangled in cables, was released by his BA partner and after approximately 16 minutes withdrew due to the further deteriorating conditions.

Attendance had been increased with a command level 2 message (automatically make pumps 5) at 18:38 and command level 3 (automatically make pumps 8) message at around 18:49. Additional special and supporting appliances had also been requested.

A 4th BA team (third team with callsign Red 1) consisting of the 4 BA wearers who subsequently died, was committed at approximately 18:53 on a right hand search with instructions to use the original extended hose reel. At approximately 19:07 a 5th BA team, another team of 4 BA (second team with callsign Red 2) entered the premises. During the course of their BA wear they heard crashing, banging and the words ‘BA emergency’. Further deteriorating conditions were described. A BA Emergency message was sent to control at approximately 19:15. Red 2 attempted to rescue Red 1. A BA wearer (WM Ian Reid) exited the fire compartment in distress and made his way past Red 2 to another location within the building where he was later found dead (WFRS & FBU Unknown date).

Further BA teams were committed to carry out rescues, including some on a guideline. Further assistance messages were sent with a make pumps 16 assistance message sent at approximately 20:01 with command level 4 in operation, requests for further special appliances and assistance from neighbouring services also made. After numerous emergency teams were committed into the building trying to rescue the missing firefighters all BA teams were withdrawn due to the conditions of the fire and the unstable structure of the building. 4 firefighters in total were killed.

This incident was also a ‘near miss’ for at least 4 further firefighters from Hereford and Worcestershire FRS as a BA team of 4, who were tasked with searching for and rescuing the missing 4 firefighters (unreferenced conversation, 2015).

Red 1, Red 2 etc are designations for BA teams that are committed to the incident. The designations were repeated after the initial BA teams designated for example, Red 1, had withdrawn.

Photo 1

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS). Unknown photographer at this time.

 Photo 2

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS).

 Photo 3

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS).

 Photo 4

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS).

 Photo 5

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS).

 Photo 6

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS).

 Photo 7

BRE reconstruction 2 images. Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS) & BRE.

 Photo 8

Heat release rates from fire tests conducted by BRE. Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS) & BRE.

 Photo 9

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS).

 Photo 10

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS). Unknown original photographer at this time.

 Photo 11

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS). Unknown original photographer at this time.

 Photo 12

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS). Unknown original photographer at this time.

 Photo 13

Pictures courtesy of Warwickshire Fire and Rescue Service (WFRS). Unknown photographer at this time.

Main findings, key lessons & areas for learning

Warwickshire Fire & Rescue Service main findings, key lessons & recommendations

Taken from; Warwickshire Fire and Rescue Service (WFRS). (unknown date). Report on the fire at Atherstone on Stour, 2nd November 2007.

--subaccordion--

LEARNING POINTS

The incident on 2nd November 2007 raised a number of learning points for both WFRS and the wider fire and rescue service sector.

 The service learning points are grouped into three main areas: operational, strategic (service level) and national.

OPERATIONAL

INCIDENT COMMAND

The Incident Commander (IC) has the ultimate responsibility for the health and safety of crews at the scene of an incident. The role involves constantly taking in information from a range of sources, prioritising that information and making decisions based on it. These decisions are dependent on the quality, accuracy and availability of information.

INFORMATION GATHERING, PROCESSING AND MANAGEMENT

The Atherstone-on-Stour incident highlighted learning points around how information was gathered, processed, and managed, in particular through:

  • Command Support
  • Briefing and de-briefing of BA crews
  • Handovers between ICs
  • Passing on of information by crews to the IC
  • Accuracy of information

Information gathering

Since the incident WFRS has identified four general headings to prompt information gathering at incidents by crews and ICs, which the service has called the ‘4 Cs’:

  • Construction (including layout)
  • Contents
  • Conditions
  • Context or circumstances e.g. casualties, time or cause

Command Support

The resources allocated to the command support function as the incident escalated were not sufficient to manage the complexity of the developing incident. The sixth appliance in attendance should have been allocated to perform the command support function but this did not happen due to it being utilised as a general fireground resource.  The learning point is that all incidents should have appropriately resourced command support from the early stages.

Briefing and de-briefing of BA crews

There was a lack of consistency in approach between commanders and BA crews to facilitate the exchange of important and relevant information. This was particularly evident at Entry Control Points although there were ad hoc briefing/debriefings taking place. The learning point is that a standard methodology should be adopted to ensure a standardised approach.

Handovers between Incident Commanders

There was a failure to document and time record the handover between ICs in the early phases up to the point when the Command Support function was fully established. There was also a lack of clear methodology in the handover. The learning point is that there should be a standardised methodology for handover between ICs.

Passing on of information by crews to the Incident Commander

There was a breakdown in communication between some areas of the fireground and those ICs making critical decisions. This resulted in important information not being passed on to those needing it e.g. the wall glowing red on the south side of the building was not passed back immediately to the IC on the opposite side of the building. The learning point is that all relevant information should be communicated (and logged) via command support as soon as reasonably practicable.

Accuracy of information

One of the main problems on the evening was the inaccuracy of the information presented, specifically the layout of the warehouse beyond the first double doors and the location of the fire.  The information presented to the ICs throughout the early phases of the incident was continually incorrect, even after revisions.  The learning point is that ICs should question and assure the validity of information given by the local on scene advisor.

FIRE SAFETY AND BUILDING CONSTRUCTION KNOWLEDGE

Post incident investigation highlighted that some of the fire safety features of the warehouse were incomplete and some these features influenced fire development. There was also a lack of understanding of modern methods of building construction by many of the operational crews. The learning point is that operational crews should be able to recognise the fire safety features and wider construction methods used in modern building, to identify potential hazards and safety features.

Identification of sandwich panels

The presence of sandwich panels in the part of the building affected was not widely recognised at the incident. The three types of construction used in the premises had been clad with the same material, of the same colour, which made recognition in the dark problematic.  The national guidance available highlighted the need to identify the presence of sandwich panels, although it did not provide guidance on method of identification. The learning point is that national guidance should clarify a consistent and practical method for identifying the presence and type of sandwich panels used within buildings (see also national ventilation work unfinished overleaf).

OPERATIONAL TACTICS

Firefighting Media

Firefighters at the incident used extended hose reels (up to 4 lengths) which was not usual practice.

The decision to use extended hose reels at the incident was driven by a number of factors:

  • previous success at the same location using this method
  • problems associated with managing large diameter hose
  • reducing air consumption en-route to the fire compartment
  • misunderstanding of the fire size, location and conditions in the fire compartment
  • WFRS has reached four main conclusions (lessons):
  • More emphasis is now contained in training and procedures on the appropriate selection
  • and use of firefighting media.
  • The number of fires attended by WFRS is reducing which has increased the importance ofby firefighters at incidents.
  • training and the need for it to incorporate a full range of situations that may be encountered
  • Extensive training in gas cooling techniques can limit the understanding and use of other
  • methods of extinguishing and controlling fires.
  • Pump operators and water sector commanders need to anticipate escalation of the incident
  • and have early arrangements for increasing the water supply.

Ventilation

Ventilation would have been extremely difficult, if not impossible to achieve safely, due to the construction of the building. The first floor storage area should have been provided with more escape routes to ensure compliance with Building Regulations. There were plans to install two further external fire escapes from the first floor storage area. If these were installed the options for ventilation would have been increased making it simpler and safer.

Aggressively making holes in the structure is always going to incur risk, for example from hitting services and encountering fire phenomenon. Previous national guidance on firefighting in sandwich panel buildings identified the need for further work and guidance around methods of ventilation.  This work has not been concluded (see National Learning Point).

Thermal Imaging Cameras

Thermal imaging cameras (TICs) are a key control measure for the fire and rescue service. Their ability to assist in both identifying casualties and locating a fire has been extremely beneficial.  When operational crews at Atherstone-on-Stour used TICs in thick smoke they showed a screen display with no contrast. The cameras were tested and were working prior to entry to the risk area.  This occurred before and after the BA emergency. During BRE’s work for WFRS they identified a possible explanation; when heavy smoke has a high concentration of carbon, a uniform heat layer can be observed through the TIC due to the ability of carbon to absorb and emit heat readily. WFRS has contacted their current suppliers of TICs who have considered the issue. They believed that BRE’s explanation is plausible but also identified some other possible causes, which include the impact on the cameras of high humidity (possible side effect of gas cooling). Unfortunately, they are unable to give an explanation unless they can recreate the effect under controlled circumstances. WFRS have made crews aware of the potential phenomenon. The lesson to be learnt is that more investigation into recognising the limitations of TIC’s is required and national guidance should be produced.

Breathing Apparatus (BA) Emergency

When the BA emergency was called there were two teams within the lift lobby area.

Fire and rescue service national guidance states that “When a distress signal is heard the team leaders of BA teams who have sufficient reserves of air are to direct their teams to investigate the source of the sound. Rendering assistance to a wearer in distress is to take precedence over the work in hand but regard must be had to keeping escape routes open and for rescues already being carried out. Once sufficient help is available any hose lines temporarily abandoned must be reinstated.”24 However no ADSU was sounding at the time of the ‘BA Emergency’ message being sent back, meaning that initial emergency crews did not have an audible target to locate.

National guidance under the heading of ‘Lost in Smoke’25 also gives guidance that emergency crews could use to locate a BA team “The branchman can always be found by following the appropriate hose line.” However in this incident this would have taken emergency crews in the wrong direction and into potential danger (accelerating fire conditions and hanging cables). The first firefighter from Red 1 encountered Red 2 in the lift lobby, but the firefighter who found him had a branch in one hand, and was therefore limited in his ability to restrain and guide him. This highlights the difficulties presented by attempting to combine firefighting or gas cooling activities with the need to carry out casualty handling. It also highlights the need for emergency teams to remain in close proximity to each other to improve team communications.

After the ‘BA Emergency’ was declared operational activities were entirely focused on rescue and the wider Incident Command considerations became secondary. Whilst an enhanced Incident Command structure was put in place at approximately 20.00 hours and water supplies were secured, no direct attack was made on the fire up until the time that all crews were withdrawn from the building. This highlights the need to put adequate command support in place from the earliest stages of an incident, and to ensure that it is appropriately resourced as the incident escalates.  After the ‘BA Emergency’ was called incident ground radio traffic increased significantly. This presented difficulties in crew to crew and crew to BAECP communication, which could have been eased by the use of additional channels.

24 Home Office Technical Bulletin 1/97 Chapter 2, CMP6C Emergency Procedures, Para. 3 25 Manuals of Firemanship, Book 11, Practical Firemanship 1, Pg. 46

Brigades should consider whether their BA refresher addresses training for BA emergencies in realistic scenarios covering unknown casualty locations, unconscious casualty handling and entrapped procedures.

Withdrawal from Building

For some time after the ‘BA Emergency’ was declared the external view of the building gave little indication of the severity of the conditions inside the fire compartment. Crews inside the lift lobby (adjacent to the fire compartment) were looking for signs and symptoms of backdraught and flashover, in accordance with their BA training, but the conditions they were encountering were not those that they had been taught to recognise. This was due to the construction methods used within the storage area. This is covered in more detail in the chapter titled ‘Understanding the Fire’.  Under section 7 of the Health and Safety at Work etc. Act 1974, General duties of employees at work: “It shall be the duty of every employee while at work—(a) to take reasonable care for the health and safety of himself and of other persons who may be affected by his acts or omissions at work; and (b) as regards any duty or requirement imposed on his employer or any other person by or under any of the relevant statutory provisions, to co-operate with him so far as is necessary to enable that duty or requirement to be performed or complied with.”26

This underscores the role that all firefighters potentially have in contributing to the information available to decision-makers. The actions by the service since have ensured those outside the building (including those with functional and command responsibilities) and those inside the building (tasked within the risk area) are all better equipped to recognise potential hazards and changing environmental conditions so that timely, informed operational decisions can be made.

Crew selection and availability

Initial resources on the incident ground were limited, which resulted in crews being combined from different stations (which is not considered best practice in Technical Bulletin 1/97) and of mixed experience. One inexperienced firefighter was committed into the building as a member of Red 2, which went against service policy at the time. The learning points from this incident are:

26 http://www.legislation.gov.uk/ukpga/1974/37/section/7

  • The need to ‘make up’ early in order to ensure that incidents are adequately resourced for
  • BA.
  • The need to consider the experience of BA wearers when assembling a BA team for a
  • particular task.
  • The importance of realistic training and development for BA wearers, given the falling
  • number of opportunities to gain real life experience.
  • The importance of reviewing service policy against what is safe and practicable.

STRATEGIC

MANAGING RISK

Premises risk information gathering and processing

Opportunities were missed prior to the incident (previous operational calls, planning lists and fire safety inspections) for WFRS to obtain risk information on the building. Up-to-date plans should have been available for crews attending the fire.

An Operational Assessment of Service Delivery (OASD) during 2006 / 2007 which included premises risk information had already identified the need for improvements to the process and at the time of the incident an action plan was in place to address these.

Given the confusion at the incident over the layout and design of the building, WFRS admitted when pleading guilty to a health and safety offence that the lack a premises risk information card or familiarisation visits may have contributed to the deaths of the four firefighters, although the crown court judge found that, if that was a factor it was a “minor one” amongst “a whole host of causes”27.

The service has introduced new policy combining Regulatory Reform (Fire Safety) Order 2005 (RRO) inspections with inspections under section 7.2(d) of the Fire and Rescue Services Act 2004. This promotes better understanding of risks within station areas and is supported by a new database and improved information exchange between fire safety, operational support and water departments.

Water supplies

Although there was no evidence at the incident of crews struggling to locate and secure water supplies for firefighting, the relevant service policy was overdue for review and meant that information relating to water supplies was not held in the agreed format (mixture of hydrant registers and local gazetteers). Crews on the night used a combination of local hydrants, a bore hole on site and eventually water relay from the River Stour to supply firefighting activities. Bomfords had planned two reservoirs at the site, which could have made firefighting more straightforward, but these were never completed. Since the incident Mobile Data Terminals have been provided on all front line appliances and information on water supplies is available to operational crews.

DOCUMENT CONTROL AND DEVELOPMENT

The investigations that followed the Atherstone-on-Stour incident found that:

  • Personnel were not universally aware of service policies and procedures, or changes to
  • them.
  • Policy and procedure that were out of date and past their review date, and obsolete policies
  • were left in the service electronic library.
  • Duplicated policies on the same subject were sometimes conflicting.
  • Policies and procedures had a lack of flexibility due to absolute phrases such as ‘must’ and
  • ‘will’.
  • Related risk assessments, procedures, and policy had contradictory statements.
  • Areas of national guidance were not considered, covered or reflected appropriately.

The service has completely reviewed and amended its guidance on the production of policies and procedures. Particular emphasis has been placed on the avoidance of ‘policy absolutes’ and duplication of information.

TRAINING AND COMPETENCE

Investigations following the incident suggested that the service’s training programme had become limited in its scope and required significant review. On station training was reviewed and there was evidence that the Integrated Personal Development System (IPDS) workplace competency approach was not meeting all of the services expectations. Personnel were training to complete portfolios rather than focussing on ‘firemanship’.

Other factors affecting WFRS training and competence are the well-known difficulties of RDS recruitment, retention and training time along with the loss of technical knowledge following the removal of the Fire Service Examination Board (FSEB).

Since the incident the service has:

  • Completely reviewed BA course content and structure against national guidance, with a
  • particular emphasis on search techniques, emergency procedures and casualty handling.
  • Invested in realistic BA and Compartment Fire Behaviour Training (CFBT), with all refresheronto flames, whilst still teaching the role of gas cooling.
  • training taking place at the Fire Service College. There is greater emphasis on putting water
  • Significantly increased the amount and quality of Incident Command training delivered with
  • the creation of an Incident Command simulator for command levels 1, 2 and 3.
  • Introduced RDS technical training by means of distance learning, enabling RDS firefighters to
  • complete technical lectures and assessments from home for payment.
  • Introduced RDS support officers to assist with training, exercises and appliance availability.
  • Introduced a Dedicated Retained Applicant Support Project to assist with RDS recruitment.
  • Placed greater emphasis on officer training through six weekly workshops and risk visits.

OPERATIONAL ASSURANCE

Since Atherstone-on-Stour, the service has looked closely at how it ensures that the training delivered is transferred onto the incident ground and how operational learning is captured. This is achieved through a combination of active incident monitoring, station audits and operational debriefs. Monitoring of learning outcomes is carried out at the operational review group and significant trends are identified and addressed.

FIRE SAFETY AND BUILDING REGULATIONS

The history of this tragedy reveals that:

  • The extension was built without plans ever having been approved by building control.
  • The storage area was put into use without the fire exit doors required by building control.
  • The fire and rescue service was not consulted about or notified of the extension 28.

The local crew became aware of the extension when called to fires there but the central team who would have received a formal consultation or notification were not notified.

All of these factors influenced what happened on 2nd November 2007 and yet no-one has been subject to legal consequences for any aspect of this state of affairs. Indeed, in the limited explanation offered by the HSE for taking no action it refers to the fact that the RRO imposes no duty on owners and occupiers to plan for the safety of firefighters: a lack of responsibility which the Crown Court Judge described as perverse.

It is beyond the remit of this report to analyse the effectiveness of the regulatory regimes governing the construction and use of commercial buildings. That is a matter for government and it is to be hoped that the operation and interface of the relevant statutory regimes revealed by this tragedy will inform its consideration of future reform.

Fire safety legislation applies to the design and use of a development. With regards to the new extension the following legislation and guidance applied:

  • Building Act 1984, Building Regulations 2000, and Approved Document B - Fire Safety (2000
  • version with amendments).
  • Construction (Health, Safety and Welfare) Regulations 1996.
  • Regulatory Reform (Fire Safety) Order 2005 (applied mainly, but previous legislation may
  • have applied for a short time).
  • Building Regulations and Fire Safety Procedural Guidance (2005 version applied mainly).

Working within the legal framework as it currently is, WFRS has identified the following learning: The fire safety framework (noted above) is largely concerned with getting occupants out of a building safely without assistance from the fire and rescue service. Much of it does not consider the safety or needs of firefighters operationally. The exception to this is building regulations Approved Document B which does cover access and water supplies for the Fire and Rescue Service.

Furthermore, a completion certificate is not needed to occupy a building, even though it is likely to be needed to sell a building, so areas of non-compliance can remain outstanding for some time. The complexities of relationships between enforcing agencies requires all parties to maintain close cooperation when dealing with significant developments.

Since the incident WFRS has reviewed how it communicates and shares information with other agencies, particularly building control, where formal arrangements are now in place.

NATIONAL LEARNING

SPRINKLERS

Sprinklers were to be provided in the area where the fire started but unfortunately these had not been completed prior to the incident. This was a recommendation from Bomford’s insurers to assure business continuity plans, as they were moving to a single centre of operations.

Had the intended system been installed and functioned correctly, the fire which developed to claim the lives of four WFRS firefighters would have been suppressed significantly, if not extinguished in the early stages of the incident.

The Building Regulations thresholds for requiring sprinklers in buildings is primarily based on building use, floor area and compartment volume. Consideration should be given at national level to the application of other criteria and ways to seek closer collaboration between planners, developers and sprinkler industry experts that encourages the wider use of sprinklers in commercial buildings.

VENTILATION

National guidance on firefighting in sandwich panel buildings should be concluded to include guidance around methods of ventilation during developed fire conditions.

FIRE INVESTIGATION TEAM

In their reports matters arising section the fire investigation team (FIT) recorded certain aspects of the incident which although they did not fall within its terms of reference, would benefit future fire investigations and help to ensure the safety of firefighters. They entitled these ‘Matters Arising’29;

  • The building was not fully completed but was occupied and in full use. It lacked adequate water supplies for firefighting purposes and planned internal fire protection measures
  • The insulation qualities of this type of modern construction create new hazards for firefighting.  The lack of natural or mechanical ventilation prevents the products of combustion being able to escape the building. The ability to identify the extent and location of a fire is impeded by these structures
  • Adequate structural means of escape routes should be provided and maintained in premises throughout its construction to ensure the safety of the people using it

29 FIT Report 1, Pg 59

  • A recommendation of this report is that the European Standard EN-54-2 "Fire detection and fire alarm systems - Part 2: Control and indicating equipment" is amended to specity that the call log data is also stored on robust non-volatile membery to assist future investigations
  • It is also recommended that the standard BS/EN 7671 "Requirements for Electrical Installations (17th Edition)" published by the Institute of Engineering and Technology is amended to require additional mechanical fixings of cables that are installed on the surface of walls and ceilings in plastic mini-trunking and or conduit.  This investigation has indentified the safety issues of firefighters becoming entangled in wiring that has fallen from plastic trunking/conduit during the fire and is suspended from ceilings in large quantities.  Previously this hazard has been identified in the investigations into the deaths of two firefighters from Hertfordshire Fire and Rescue Service at Harrow Court in February 2005.
  • It is imperative that when administrators are called in to take responsibility for a business, that matters of safety are not deferred pending the outcome of the insolvency proceedings.  A fire investigation response to incidents of this magnitude requires a national arrangement to ensure adequate resources are available.  Where incidents involve firefighter fatalities the fire investigation team shout be independent of the affected Fire and Rescue Service".

BRE GLOBAL REPORT

The BRE Global work (reviewed in the chapter titled ‘Understanding the Fire’) highlighted a number of issues which BRE Global and WFRS are of the opinion need further consideration. These are taken from the ‘Matters arising from this programme of work’ section of BRE Global report on the Atherstone-on Stour-incident for Warwickshire Fire and Rescue Service.

17.1 Highly insulated buildings

Highly insulated buildings are becoming increasingly popular as a means of reducing the energy consumption of buildings. BRE Global’s sustainability experts are heavily involved in the development and certification of highly insulated buildings of all sizes, ranging from domestic properties through to commercial offices, industrial buildings and warehouses. The popularity of these buildings is driven by the sustainability agenda, which currently carries far more interest in the construction industry and is currently achieving far more rapid development than the fire safety agenda. As the level of insulation afforded to buildings increases, two factors pertaining to the fire are affected:

The ability of these buildings to contain heat from a fire increases. This means that less energy is required to heat a room to the point where flashover might occur and the temperatures that can be achieved during a fire are increased. The external indicators that a fire is occurring are reduced. Highly insulated buildings also need to be well sealed. Any and all gaps or cracks (or other openings) in the building envelope allow heat to leak out, reducing the thermal efficiency of these buildings and reducing their environmental performance. As a result of the extra steps that are taken to seal these gaps, less smoke from a fire will be able to exit the building to be seen by passers-by or members of the Fire and Rescue Service attending an incident, see Chapter 13.3.

17.2 Rapid fire growth

Partly as a side effect of the increased insulation afforded to buildings, but also a result of changing materials present in and around buildings, rapid fire growth is becoming increasingly common. During the course of carrying out the reconstructions it was noted that modern Fire and Rescue Service training involves the use of simulator units. These units often show fire fighter trainees fires that burn at a steady rate for a considerable period of time. They do not show a fire growing suddenly from a relatively small, well contained fire to a fire that is engulfing an entire compartment and extending beyond the boundaries of a compartment. As a result trainees are not necessarily taught how to identify signs and symptoms of impending sudden fire growth and how to respond to these signs and symptoms.

17.3 Large compartments

Fire safety issues around large compartments have been known to Fire and Rescue Services for some years. Large compartments provide particular challenges because fires can be difficult to find within large compartments and it can be relatively easy to become disorientated within a large compartment, particularly if it is sub-compartmented or filled with materials or machinery. The other issues that have been identified in this chapter need to be considered for all sizes of compartments including large compartments.

17.4 Gas cooling within large compartments

As previously mentioned, BRE Global does not possess expertise in firefighting operations. However, BRE Global has some concerns regarding the use of gas cooling in such a large and hot compartment since the physics involved in gas cooling raise some interesting issues. Given the size of the compartment of the first floor storage area of Wealmoor Atherstone, it would require a very large amount of energy to raise the temperature of the entire quantity of air within the volume. As such, once all of the air in the volume was at an elevated temperature, it would be necessary to remove a very large amount of energy to appreciably reduce the overall temperature. The act of gas cooling introduces a fine spray of water droplets into a hot smoke layer, the intention being that the water droplets will absorb heat from the hot smoke layer, most effectively when evaporating in the process. Cooling the smoke layer helps to reduce temperatures generally within a compartment and can cause the smoke layer to rise up away from firefighting crews due to it contracting as it cools (provided the smoke layer is not disturbed too greatly by the action of the jet).

However, in doing so, the humidity of the compartment is increased. Increased humidity increases the specific heat capacity of the atmosphere and increases the ability of the atmosphere to transfer heat to firefighting personnel. Fire fighters are therefore trained to gas cool without unduly increasing the humidity of the atmosphere.

With a compartment the size of the first floor storage area of Wealmoor Atherstone, even if gas cooling were being carried out as efficiently as possible, it might not be possible to achieve a balance between reducing temperatures and minimising humidity. Applying gas cooling to an area within such a large compartment may cool the local environment around a fire fighting crew, but it would be unlikely to cool the entire compartment. Following gas cooling, the surrounding hot gases would be drawn in to replace the contracting cooled gases and fill the space, albeit now with the humidity that has been increased by the gas cooling. This could lead to temperatures being largely unchanged compared with what they were prior to gas cooling but with an increased humidity and associated heat transfer to the firefighting crew. This phenomenon would account for the wall of heat described by crews during the incident. This needs to be investigated further to be validated and assess its significance.

17.5 Cable trunking

Cable trunking has shown to be an issue in this incident as it has been in previous incidents, including the fire at Harrow Court in 2005. It is understood by BRE Global that work is being carried out elsewhere to investigate the feasibility of using fixings that will not be susceptible to elevated fire temperatures. The findings from this work need to be fed into the ongoing work to ensure that an appropriate solution is achieved.”

Warwickshire Fire and Rescue Service have already, with the assistance of Chief Fire Officers Association (CFOA), issued operational bulletins nationally based on the above points. The bulletins apply a Fire and Rescue Service perspective to the issues and were created with assistance from BRE Global.

OCCUPATIONAL HEALTH AND TRAUMA SUPPORT

The occupational health team, the trauma support team and the welfare adviser have been invaluable in helping the crews who attended Atherstone-on-Stour and the wider service deal with the tragic outcomes of the incident. As well as being the right thing to do, this has resulted in low levels of related sickness and has been recognised as notable practice following the operational peer assessment review in November 2013.

In 2014 the service has invested in training a small group of volunteers as family contact officers who aim to provide care, support and information exchange in a sensitive and compassionate manner to bereaved family members/next of kin. Built on the learning experiences from this incident the intention is that this group will add further support and consistency in dealing with these types of tragedies.

WARWICKSHIRE FIRE & RESCUE SERVICE ADVERSE EVENT INVESTIGATION TEAM

The Warwickshire Fire & Rescue Service Adverse Event Investigation Team report, completed in September 2008, made a range of national recommendations:

  • Clarification is required at national level concerning the Manuals of Firemanship, in particular which of them are still extant and which will enable local policy to be correctly and inconfidently developed.
  • The National Occupational Standards do not clearly assess Crew Manager and Watch Manager on the 'demonstations of search and resuce techniques' and should be reviewed and amended.
  • The procedure to adopt when hearing a Distress Signal Unit operating is well documented but the actions to be taken on hearing a BA Emergency called without a DSU operating are not and should be clarified and included in national guidance.
  • The ‘Facefit’ testing guidance agreed with the Health and Safety Executive should bei ncluded in TB 1/97.
  • TB 1/97 should be reviewed taking into consideration the following points:

 

  • How Brigades should use and follow the guidance in TB 1/97
  • Clarify the need to consider blast zones when positioning Entry Control Points
  • Consideration should be given to the practice of Colour designating Entry Control Points to aid BA communication.
  • That the guidance that refers to TB 1/97 is reviewed and updated or removed,
  • specifically the Manuals of Firemanship.
  • The emergency procedures under Stage I should be reviewed specifically the potential non availability of an emergency crew should a BA emergency occur whilst under Stage I conditions.
  • Command Support should record the transfer from Stage I to Stage II procedures.
  • Only the Brigade whose area the incident is in should open and run Stage 2 Entry Control Points but which may be supported by resources from over the border.
  • A second board and assistance should be provided following BA emergency to preserve the evidence on the first board and to provide extra support to the existing Entry Control Officer.
  • The transfer from one Entry Control Officer to another Entry Control Officer due to the relief crews arriving should involve a check of the original time of whistles. An
  • alternative could be the use of a completely new board for the new officer.
  • Clarification is required of the term used to describe the Emergency Teams following the first Emergency Team being committed after a BA Emergency. The term ‘Rescue Team’ may be more appropriate.
  • Clarification is required on the competencies required of a Main Control Officer which should include detail on how they should be maintained.
  • The Entry Control Officer is aware of a great deal of information and assessments made by BA crews and Officers concerning that Entry Control Point and Operations. That information and risk assessments of the crews and command officers should be recorded and made available to the next BA Entry Control Officer, Officers and subsequent BA crews.
  • Assess the guidance given within TB 1/97 concerning the supervision levels and how this fits in with the current Incident Command System.
  • TB 1/97 states that BA sets will be tested daily on station and the log book completed. This is an issue with the Retained Duty System as these crews may be relying on a set that was signed for up to a week before.
  • Consideration should be given to a way of recording and protecting information on Entry Control Boards for debriefing and accident investigation purposes.
  • The practice of using Guidelines alongside hose-lines should be reassessed and guidance issued clarifying guidelines use if necessary.
  • TB 1/97 states that BA set tallies should be permanently marked with the station name which causes problems when the sets move from station to station or into a BA
  • equipment pool. This inclusion should be reviewed and amended.”

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

--end--

FBU summary of main findings, key lessons & recommendations

Taken from; The Fire Brigades Union (FBU). (unknown date). Fatal Accident Investigation – Summary report into the deaths of Ian Reid, John Averis, Ashley Stephens and Darren Yates-Bradley at Wealmoor (Atherstone) Ltd, Atherstone on Stour, Warwickshire.

--subaccordion--

6.1 Specific conclusions

6.1.1 IRMP

Fundamentally, the events on that fateful evening of 2 November 2007 were a catalogue of organisational systemic failings. The disaster started with the failure to deliver an effective IRMP prior to the incident, which should have identified Hangars 1 and 2 as a significant risk to firefighters. This responsibility lies not only with Warwickshire Fire and Rescue Authority (WFRA) but with central government to ensure sufficient funding is in place to deliver an effective, monitored IRMP. Risk information/fire plan would also have been available if the IRMP process had been applied correctly. With the correct application of the IRMP process the sufficient funding, risk information and resources required to deal with such a significant risk would have been in place. Subsequently this would have also highlighted the training required to deal with such an incident to bring it to a safe and satisfactory conclusion.

6.1.2 FSEC

Following the Operational Assessment of Service Delivery 2006, Warwickshire Fire and Rescue Service (WFRS) were made aware of areas for improvement with regard to developing a full risk profile of Warwickshire. If this process had been completed and the FSEC database fully populated with current data, the toolkit if used correctly would have contributed to the IRMP process. This large piece of work was several years away from completion due to lack of resources within WFRS.

6.1.3 Training

Training within WFRS was also a significant factor contributing to the failures within the organisation. The areas that were identified were predominantly surrounding the functions that were carried out on the evening of the 2 November 2007. These were risk information, risk assessment, breathing apparatus procedures/command and control and incident command. Quality assurance of the training delivered in WFRS had also been identified as a significant issue.

6.1.4 Risk assessment

WFRS had a service order (03.16.06) that details the procedure for operational premises risk assessment. A building of sandwich panel construction is seen as a significant hazard requiring the minimum of the production of an O2 risk information card or possibly a more detailed fire plan of the premises. This procedure failed on two occasions. Firstly, local building control at planning stage, where all of the hazards aligned with this type of construction should have been identified. Secondly, as a result of a previous incident a fire safety officer carried out an inspection of the premises due to fire safety issues that were identified, during this inspection it was recognised that the building was of sandwich panel construction. Both occasions should have triggered the process detailed in the service order for a premises risk assessment. This process should have also ensured that sandwich panel construction was detailed on the mobilising turnout sheet. All of which was also seen as an area for improvement in the Operational Assessment of Service Delivery 2006 with regard to the passage of information between operational crews and fire safety staff and vice versa. Additionally the assessment also criticised the premises re-inspection programme where it was identified that a random selected premises contained hand written amendments that had not been added to the central database, therefore some crews attending the site may not have possessed up to date risk information.

6.1.5 Recording training

It is unknown if all staff received training on the delivery of service orders or any other written communication as there was no evidence (records) to confirm the delivery of this type of information to WFRS staff. The method of recording training in WFRS was a computerised system called Redkite for Wholetime firefighters. For retained duty system (RDS) staff it was largely a paper-based recording system. Neither system provided a means to ensure the quality of delivery, underpinning knowledge gained and competence of WFRS firefighters. It was also identified that there was no robust process for the recording of training for officers and assessment of continued competence.

6.1.6 BA training

BA training requires a complete overhaul, including identified courses, syllabus content and course duration. For example the initial BA course for RDS staff had been reduced and does not comply with national guidance. Also BA refresher training was sacrificed for the introduction of fire behaviour training thus no longer maintaining core skills. The BA refresher course must be reintroduced as per national guidance and should be delivered as a separate entity to the fire behaviour course. Because of the introduction of Integrated Personal Development System (IPDS), the ideal around this was for individuals to self nominate for mandatory BA refresher courses. This obviously failed as records identified that some staff had not completed BA refresher training for many years.

6.1.7 RDS database

The Operational Assessment of Service Delivery 2006 also stated that the development and maintenance of RDS staff differs significantly to that delivered to wholetime personnel. It also identified that the monitoring, recording and auditing of training activity and assessments of RDS personnel was weak with no central database to demonstrate RDS workforce competence. However, during the investigation it was found that deficiencies in this area also extended to wholetime personnel including officers.

6.1.8 Computer based training

Computer based training was the only method of delivering various functions including Incident Command, which occasionally was monitored during exercises. This system does not provide a robust assessment of underpinning knowledge. Many WFRS firefighters see it as a team event as opposed to individual training and assessment.

6.1.9 Command Support

Command Support also forms an important function with the incident command system. As a result of this, that evening there were significant errors that affected the delivery of command support. In WFRS there is limited training delivered in command support especially in the completion of risk assessments, therefore there was no written evidence recorded of risk assessments during the offensive operations of the incident. The command point had to be moved on a number of occasions from the back of one appliance to another for various reasons with the firefighter carrying vehicle nominal roll and officer fobs in his fire helmet. Furthermore there was no sector commander or dedicated crew identified for the additional support for command support as the incident progressed.

6.1.10 Appliances

The Control Unit had been off the run for a considerable time and no contingency plans had been put in place meant that the BA Pod had to be used for two functions, Command Support and BAMC. One appliance carrying out two functions means that there must be a competent and dedicated crew for each function.

6.1.11 Monitoring

It has already been mentioned that the Operational Assessment has identified areas for improvement regarding training of staff. Workplace assessments at incidents were also criticised with no evidence of monitoring staff performance.

6.2 General conclusions

6.2.1 Serious Accident Investigation process

The primary purpose of the FBU’s Serious Accident Investigation (SAI) process is to prevent the serious injury or death of firefighters at similar incidents in the future. This summary report highlights three broad areas:

  • IRMP
  • Incident Command and Control
  • Use of and Command and Control of Breathing Apparatus

6.2.2 IRMP

Every firefighter accepts that there exists an element of risk associated with the work that they are required to undertake. However what comes with this expectation is a belief that their employer will have done everything within their powers to minimise any potential and foreseeable risk that does exist by carrying out an exhaustive risk analysis, planning and resourcing exercise in the form of an IRMP. The section on IRMP above highlights a number of inadequacies with the IRMP process undertaken by WFRS prior to and at the time of this incident. These recommendations are not exhaustive and further reference should be made to the full SAI report. The FBU believes that the issue of IRMP is one that should not just be the subject of local scrutiny by WFRS alone, but that it should be an area that government, employers and the HSE should take a greater interest in. There is a need for greater scrutiny in regard of the drafting, implementation and adequacy of IRMPs. It seems that too much emphasis is placed on the way the plans are drawn up and far too little on what they actually mean and what they are able to deliver in the form of an effective fire and rescue service.

6.2.3 Incident Command and Control

Assuming that a fire and rescue service IRMP has determined that a particular risk exists and that as a fire and rescue service they have a duty to attend incidents at such a risk, it should go without saying that the service’s IRMP should indicate what the expected outcome of that attendance should be. In order for this to be the case it is incumbent on the fire and rescue service to have undertaken the previously mentioned risk analysis exercise in order to formulate a plan and to calculate necessary resources to facilitate the expected outcome. Only by undertaking this exercise can Incident Commanders decide upon fireground tactics and strategy and importantly whether they have sufficient resources available at any time throughout the duration of an incident to meet fire and rescue service expectations. With regard to this particular incident, the quality of information available to the initial incident commander whilst en route and whilst in attendance was inadequate, calling into question not just the IRMP process, but also the operational pre-incident planning process for this particular site. In essence this made effective incident command an impossibility from the outset and the Incident Commanders and crews were effectively set up to fail.

6.2.4 Breathing Apparatus

The vast majority of on duty deaths involving firefighters take place whilst they are wearing BA. It is frustrating that the FBU are too often required to contribute in one form or another to proposals on guidance referring to the use of BA; a number of which we view as a dilution of current arrangements. It stands to reason that whilst current arrangements do not prevent the loss of firefighters whilst wearing BA, any proposed guidance of a less stringent nature would lead to an increase in similar events. This would be totally unacceptable. This is why we have made a number of recommendations that seek to improve the guidance employed in the use of, and control of, BA. Some of these recommendations are applicable to WFRS but equally other fire and rescue services would do well to carry out similar exercises. Some of the recommendations refer to issues which we feel would be best dealt with nationally.

6.2.5 Other concerns

The three areas mentioned above do not form an exhaustive list of topics addressed within the full FBU SAI report, nor do they address all of our concerns in the three particular areas themselves. However they do constitute three key areas of concern where we believe the fire and rescue service is not learning from its previous mistakes. All too often when incidents such as these are dissected, as they always are, do we draw comparisons to other incidents. Until such time as all concerned acknowledge this and make a concerted effort to address the underlying issues, the FBU remains gravely concerned that similar tragic events will take place in the future. The conclusions and recommendations are based on the information, evidence and documentation that has been made available to the FBU and to the best of our knowledge was accurate at the time of producing this report. We emphasise that any additional information subsequently becoming available could alter the findings of this and any future reports.

7) Specific conclusions

The FBU’s full Serious Accident Investigation (SAI) report into the deaths of four firefighters on 2 November 2007 makes a detailed series of recommendations, divided into ten separate headings to ensure effective operational service delivery:

  • National Framework
  • Integrated Risk Management Plans (IRMP)
  • Risk information
  • Incident Command System
  • Dynamic Risk Assessment
  • Breathing Apparatus (BA)
  • Water supplies
  • Operations
  • Fire development and firefighting actions In this summary report, three key areas of recommendations have been extracted.

7.1 IRMP

7.1.1 Central government must undertake a review of the IRMP guidance notes as a matter of urgency with all stakeholders fully involved. The outcomes of the review to be published and implemented.

7.1.2 Central government must introduce a robust process of scrutiny that demonstrates that a risk based approach has been applied to the production of local IRMPs.

7.1.3 DCLG must issue a circular immediately to advise that fire and rescue authorities must have regard to Fire and Rescue Authorities – Health, safety and welfare framework for the operational environment, published in June 2013, when developing their IRMP. The FBU should ensure the same issue is raised elsewhere in the UK.

7.2 Incident Command

7.2.1 In 2007 the Warwickshire Fire and Rescue Service Incident Command System was operating to Fire Service Manual, Volume 2, Fire Service Operations, Incident Command, second edition. The fire and rescue service must ensure the best possible operational intelligence is available en-route and at the incident ground from owners and managers of the site.

7.2.2 Communication across all areas of the incident ground must be more effective.

7.2.3 Warwickshire Fire and Rescue Service must review and update S.O. 01.02.21 Incident Command System, in recognition of the importance of communication on the incident ground. This must include risk, task and deployment information. This should be completed within twelve months.

7.2.4 Robust training must be provided in recognition of the importance of communication on the incident ground. This must include risk, task and deployment information to all firefighters and sector commanders.

7.2.5 At all incidents there is always an element of risk and the level of risk must always be balanced against what will be gained. To achieve this, an assessment of the risk must be carried out and this process must continue at regular intervals throughout the incident. Warwickshire Fire and Rescue Service computer-based training lecture package on Command Support details the function of gathering written risk assessments from the incident. Risk assessments must be recorded and risk information passed on to attending crews.

7.2.6 Warwickshire Fire and Rescue Service must review and update S.O. 01.02.21 Incident Command System, in recognition of the importance of risk assessment and the introduction of any relevant control measures on the incident ground and to reflect current fire and rescue service national guidance and best practice. This should be completed within twelve months.

7.2.7 Risk assessment is a management responsibility and therefore must be carried out in line with the Management of Health and Safety at Work Regulations 1999 (MHSWR 1999) and undertaken by crew managers or above.

7.2.8 Robust training must be provided on carrying out a risk assessment on the incident ground to all crew managers and above, and undertaken annually.

7.3 Breathing Apparatus

7.3.1 Agreement needs to be reached on the replacement for TB 1-97. The new policy must ensure no reduction in the various safety measures and safeguards contained within current guidance and should, where possible, improve safety related safeguards.

7.3.2 Whilst WFRS has in place Service Order 05.04.10, a review/audit of this service order needs to be implemented to ensure compliance with the fire and rescue service national guidance and best practise on selection of BA teams leaders and BA wearers. It should further ensure a robust process is in place to demonstrate that all firefighters and incident commanders have gained the underpinning knowledge essential for ensuring that they can carry out their functions safely.

7.3.3 A singular national system for the designation of BA Entry Control Points and the numbering of BA teams should be adopted to remove confusion and improve interoperability between fire and rescue services. Such a system can only be guaranteed with the introduction of robust training, policies and procedures thus allowing firefighters and incident commanders to deliver on a consistent basis. The attainment and maintenance of these skills should be validated on an annual basis in order to ensure the implementation of ongoing safe systems of work.

7.3.4 Where BA wearers are to be re-committed, then such a commitment should be for a specific task only and must have due regard to the fitness of BA wearers. It is crucial for officers in charge and all BA wearers to recognise the signs and symptoms of heat stress and other thermal-related health and performance issues or conditions i.e. experiencing dizziness, nausea, abdominal pain, or a burning sensation of the skin, illogical decision making, or other unusual cognitive behaviour. The accurate recording of BA wearers names; time of entry and exit, a brief description of the conditions and activity must also be recorded. In view of the serious issues surrounding the re-committing to an incident of firefighters in BA, this issue should be kept under review by all stakeholder. These considerations should take account of developing knowledge regarding the physiological effects of wearing BA in fire situations.

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

FBU summary of main findings, key lessons & recommendations

Taken from; The Fire Brigades Union (FBU). (unknown date). Fatal Accident Investigation – Full report into the deaths of firefighters John Averis, In Reid, Ashley Stephens and Darren Yates-Bradley at Wealmoor (Atherstone) Ltd, Hangers 1 and 2, Atherstone Industrial Estate Atherstone on Stour, CV37 8BJ.

7. Conclusions

No effective IRMP

7.1 Fundamentally, the events on that fateful evening of 2 November 2007 were a catalogue of organisational systematic failings.

7.2 The idea that local fire and rescue authorities should have the freedom to identify their own risks, evaluate their own arrangements and set their own policies and standards is now well entrenched and is unlikely to be reversed in the foreseeable future.

7.3 However local freedom should not extend to the freedom to adopt such a poor planning process that risks are not identified, arrangements are not evaluated and policies and standards are not set.

7.4 When national standards of fire cover were removed in 2003/4, the IRMP process was introduced as an open and transparent, publicly accountable alternative.

7.5 In the period from 2004 to the events of November 2007, WFRS had not implemented the IRMP process and had therefore effectively been operating for three and a half years without either national or local standards of performance.

7.6 The disaster started prior to the incident with the failure to deliver an effective integrated risk management plan (IRMP), which should have identified Hangars 1 & 2 as a significant risk to firefighters. This responsibility lies not only with Warwickshire Fire and Rescue Authority but central government to ensure sufficient funding is in place to deliver an effective, monitored IRMP. If the IRMP process had been applied correctly, sufficient funding, risk information, a fire plan and the resources required to deal with such a significant risk would have been in place. This would have also highlighted the training required to deal with such an incident to bring it to a safe and satisfactory conclusion.

Lack of current data on the Fire Service Emergency Cover (FSEC) toolkit database

7.7 Following the Operational Assessment of Service Delivery 2006/07, WFRS was made aware of areas for improvement for developing a full-risk profile of Warwickshire. If this process had been completed and the FSEC database had been fully populated with current data, the toolkit, if used correctly, would have contributed to the IRMP process. However, this large piece of work was several years away from completion due to lack of resources within WFRS.

No premises risk information

7.8 WFRS had a Operational Training Instruction (OTI 03.16.06) that details the procedure for operational premises risk assessment. A building of sandwich panel construction is seen as a significant hazard requiring the minimum of the production of an O2 risk information card or possibly a more detailed fire plan of the premises. This procedure failed on two occasions:

  • firstly, at the planning stage when local building control failed to identify the hazards of this type of construction, and
  • secondly, when a fire safety officer inspected the premises following a previous incident and it was recognised that the building was of sandwich panel construction.

7.9 Both occasions should have triggered the process detailed in the service order for a premises risk assessment. This process should have also ensured that sandwich panel construction was detailed on the mobilising turnout sheet.

7.10 All of this was also seen as an area for improvement in the Operational Assessment of Service Delivery 2006/07 with regard to the passage of information between operational crews and fire safety staff and vice versa. The assessment also criticised the premises re-inspection programme because a randomly selected premise contained hand written amendments that had not been added to the central database. Therefore, some crews attending the site may not have possessed up-to-date risk information.

7.11 While a review of the fire risk assessment would have focussed on the potential causes of fire in and around the building and on the means of escape for occupants, it would have also have delivered indirect benefits in terms of firefighter safety.

7.12 Firstly, such a review would have highlighted the importance of missing fire safety systems. With the missing fire doors, the lack of an alternative means of escape was a matter of occupant safety not a firefighting issue. However, had means of escape been located in the appropriate positions, firefighters would have had better access to the fire compartment, which would have aided firefighting operations. This would include BA entry procedures and the venting of smoke and heat from the fire compartment.

7.13 As for the water mist fire suppression system, it may well be the case that, had a fire suppression system been fitted, the fire would have been brought under control automatically and the tragic events of 2 November 2007 would not have unfolded. However, there is no requirement in law to provide a fire suppression system in such an industrial/storage building.

7.14 Secondly, people who are responsible for the fire safety of buildings are encouraged to incorporate into their fire risk assessment a simple line drawing of the building to help them check their fire precautions.

7.15 By completing such a line drawing, the new owners would have had at least one drawing that would have been a reasonable approximation to the internal layout of the premises. This would have proved invaluable to WFRS on the evening of the fire.

Lack of training

7.16 Training within WFRS was also a significant factor contributing to the failures within the organisation. The areas that were identified were predominantly surrounding the functions that were carried out on the evening of 2 November 2007. These were risk information, risk assessment, breathing apparatus procedures/command and control and incident command. Quality assurance of the training delivered in WFRS was also a significant issue.

7.17 It is not known whether all staff received training on the delivery of service orders or any other written communication as there was no evidence (i.e. records) to support the delivery of this type of information to WFRS staff. The method of recording training in WFRS was a computerised system called Redkite for wholetime firefighters, while for RDS staff it was largely paper-based training. Neither system provided a means to ensure the quality of delivery, underpinning knowledge gained and competence of WFRS firefighters. There was no robust process for the recording of training for officers and assessment of continued competence.

7.18 The construction of the Wealmoor premises with its large compartments created issues for firefighters whose training left them ill-prepared to deal with fires in such buildings.

7.19 There were serious failings in BA training. For example, the initial BA course for RDS staff had been reduced and did not comply with national guidance. Contrary to national guidance, BA refresher training was dropped as a separate entity and became part of fire behaviour training which meant that core skills were no longer maintained.

7.20 Because of the introduction of IPDS the ideal around this was for individuals to nominate themselves for mandatory BA refresher courses. This obviously failed, as records identified that some staff had not completed BA refresher training for many years because a robust system was not in place.

7.21 The Operational Assessment of Service Delivery 2006/07 also stated that the development and maintenance of RDS staff differed significantly to that delivered to wholetime personnel. It also identified that the monitoring, recording and auditing of training activity and assessments of RDS personnel was weak with no central database to demonstrate RDS workforce competence. However, during the investigation it was found that deficiencies in this area also extended to wholetime personnel, including officers.

7.22 Computer-based training was the only method of delivering various functions, including incident command, which occasionally was monitored during exercises. This system does not provide a robust assessment of underpinning knowledge.

Failures of the incident command system

7.23 During the course of the incident, there were numerous failures of the incident command system which resulted in confusion, lack of information and, tragically, exposure of firefighters to unnecessary danger. Examples of these failures are recorded in Section 4, Sequence of Events of this report.

7.24 Command support forms an important function with the incident command system but on that evening there were significant errors that affected the delivery of command support. In WFRS there was only limited training delivered in command support, especially in the completion of risk assessments. This led to no written evidence recorded of risk assessments during the offensive operations of the incident. The command point had to be moved on a number of occasions from the back of one appliance to another for various reasons with the firefighter carrying the vehicle nominal roll and officer fobs in his fire helmet. Furthermore, there was no sector commander or dedicated crew identified for the additional support for command support as the incident progressed.

7.25 The control unit had been off the run for a considerable time and no contingency plans had been put in place, which meant that the BA pod had to be used for two functions, command support and BAMC (breathing apparatus main control). If one appliance had to carry out two functions there should have been a competent and dedicated crew for each function.

7.26 There was no evidence of monitoring of staff performance at the incident despite the fact that the Operational Assessment, previously mentioned, had criticised workplace assessments at incidents. 

8. Recommendations

8.1 The following recommendations are broken into a number of different headings. These recommendations are not laid out in an order of priority, they are, in the opinion of the Fire Brigades Union, all important to ensure effective operational service delivery:

  • Frameworks for fire and rescue services in England, Scotland and Wales
  • Integrated risk management plans (IRMP)
  • Risk Information
  • Incident command system
  • Dynamic risk assessment
  • Breathing apparatus
  • Water supplies
  • Operations
  • Fire development and firefighting actions
  • General.

Frameworks for fire and rescue services in England, Scotland and Wales

8.2 Further guidance on writing and constructing an IRMP should be included in the national framework.

8.3 Stakeholders should be fully consulted and amendments to the framework published by fire and rescue service circular and laid in parliament for approval.

8.4 Whatever guidance is contained in future national framework documents, Warwickshire FRS must examine past national frameworks and earlier government guidance to ensure that its IRMP is fit for purpose.

Integrated risk management plans (IRMP)

8.5 The Office of the Deputy Prime Minister (ODPM) published guidance notes on constructing and writing an IRMP but these have not been updated since their inception in 2002/03.

8.6 Central government should undertake a review of the guidance notes as a matter of urgency and all stakeholders should be involved and the outcome of the review published and implemented.

8.7 The improvements to the guidance notes promised in 2009 by the then fire minister Sadiq Khan should be included in the review.

8.8 As a matter of urgency, the guidance notes must ensure employee safety is introduced into future IRMPs and, in Wales, RRPs (Risk Reduction Plans).

8.9 Government should introduce a robust process that demonstrates that a risk-based approach has been applied to the review of the guidance notes.

8.10 There should be an audit and review process to ensure that the guidance notes are current and ensure advice on constructing an IRMP is consistent with the national framework objectives.

8.11 The secretary of state should ensure that central government conducts a robust audit process of individual FRS IRMPs during the IRMP consultation phase to ensure compliance with current guidance.

8.12 The DCLG committee should ensure that the secretary of state’s responsibilities are delivered.

8.13 Following the deaths of nine firefighters who died on duty between April 2007 and March 2008 the FBU produced a report In The Line of Duty which made a number of recommendations to improve IRMPs. Warwickshire FRS should implement these recommendations to prevent such deaths in the future.

8.14 WFRS should examine in detail the government guidance for producing an IRMP and should observe that guidance in letter and in spirit.

8.15 Warwickshire FRA needs to understand the role that it plays in the IRMP process and thoroughly scrutinise future plans. The FRA should not only question what is in an IRMP, it should also understand what should be in the plan and raise questions if those matters are left out.

8.16 WFRS integrated risk management plan should contain assessments of all risks within its geographical area and identify the appropriate resources to deal with any incident to ensure safe systems of work and the correct application of risk management.

8.17 The IRMP and annual action plans must be an accurate reflection of the organisation’s approach to risk and actual activity, objectives and the safe delivery of risk management services, particularly intervention and prevention. This must be integrated into the business planning process.

8.18 DCLG FRS operational guidance document Operational Risk Information and Risk and Response the Emerging Dynamics of Major Incidents in Public Services and Civil Society by Zurich Municipal, the insurers of many FRSs, should be used when compiling IRMPs and annual action plans.

8.19 Current fire and rescue service operational guidance, generic risk assessments and their outcomes must be considered prior to constructing the IRMP.

Risk information

8.20 The Operational Assurance Service Assessment carried out in 2006/07 identified that WFRS had not fully populated the FSEC model with data covering all commercial premises, therefore it was not possible to deliver a risk-assessed IRMP. The lack of a robust system had been identified during the Operational Assurance Service Assessment where high-risk premises were identified and risk information had not been transferred to the central data base, meaning that some crews attending the premises would not posses all the updated risk information. Therefore WFRS should ensure a robust system for gathering and disseminating risk information on all commercial properties is implemented. This should include a review process.

8.21 The OPDM produced health and safety guidance for FRSs, part of which was Volume 3 of the Guide to Operational Risk Assessment which included generic risks assessments (GRAs). The intention of these GRAs was to inform the local risk assessment process.

8.22 WFRS should comply with the current GRA 3.1 Fighting Fires in Buildings.

8.23 WFRS should develop their own risk assessments based on the hazards identified in GRA 3.1 and any other hazards identified during the premise risk information gathering.

8.24 There are serious risks associated with large volume buildings.

8.25 WFRS needs to introduce a robust process that informs all firefighters and incident commanders of the current risks associated with large volume buildings to enable them to carry out their functions safely.

8.26 Planning is key to enhancing the safety of firefighters and others likely to be affected by FRS operations. OTI 03.16.06 was based on the Fire and Rescue Services Act 2004 section 7.2d, The Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999.

8.27 WFRS should replace OTI 03.16.06 with a new policy and process that gathers, provides and disseminates current premises risk information and ensures that it is available to all responding crews at incidents.

8.28 This information should include: levels of response; relevant standard operating procedures (SOPs); tactical considerations, including rendezvous points, appliance marshalling areas, achievable outcomes, and access points as well as site specific hazards; and identification and, where   necessary, formal notification to person(s) responsible for the site of any FRS operational limitations.

8.29 There needs to be a regular audit and review of the policy and process to ensure that it is current and delivering as intended.

8.30 WFRS needs to train all relevant personnel in basic fire safety measures to enable personnel to identify omissions and hazards when conducting risk information gathering visits.

8.31 WFRS should train all relevant personnel in the revised policy on the gathering, providing and disseminating premise risk information.

8.32 Warwickshire FRS should introduce a robust process that demonstrates that all relevant personnel have gained the underpinning knowledge and understanding of the above to enable them to carry out their functions safely.

8.33 There should be an audit and review process to ensure that the training implemented is current and ensures competence of all relevant personnel.

Incident command system

8.34 In 2007 the WFRS Incident Command System was operating to Fire Service Manual, Volume 2, Fire Service Operations, Incident Command, second edition. Operational intelligence available on-route and at the incident ground from occupier was poor and misleading.

8.35 Operational intelligence at an incident comes in various sources. One single source should not solely be relied upon to formulate a tactical plan. Therefore WFRS needs to review and update S.O. 01.02.21 Incident Command System with regards to operational intelligence to reflect current fire service national guidance and best practice.

8.36 Robust training needs to be provided on gathering of operational intelligence and decision making to incident commanders.

 Photo 14

The relationship between risk and degree of supervision

8.37 There was ineffective communication across all areas of the incident ground resulting in lost information and self deployment.

8.38 WFRS should review and update S.O. 01.02.21 Incident Command System to recognise the importance of communication on the incident ground. This needs to include risk, task and deployment information and should be completed as soon as possible.

8.39 Robust training needs to be provided on recognising the importance of communication on the incident ground, including risk, task and deployment information to all firefighters and sector commanders.

8.40 WFRS should introduce a robust process that demonstrates practically that all firefighters and sector commanders have gained underpinning knowledge and understanding of the above, on an annual basis, to enable them to carry out their functions safely.

8.41 There should be an audit and review process to ensure that policies and procedures implemented are current and ensure competence of firefighters and sector commanders.

8.42 At all incidents there is always an element of risk and the level of risk must be balanced against what will be gained. To achieve this, an assessment of the risk must be carried out and this process must continue at regular intervals throughout the incident. WFRS computer-based training lecture package on command support details the function of gathering written risk assessments from the incident. However, during the incident there was no evidence of any dynamic or analytical risk assessments being recorded, and as such no risk information was passed on to attending crews.

8.43 WFRS needs to review and update S.O. 01.02.21 Incident Command System to recognise the importance of risk assessment, to introduce relevant control measures on the incident ground, and to reflect current fire service national guidance and best practice.

8.44 Risk assessment is a management responsibility and therefore must be carried out in line with the Management of Health and Safety at Work Regulations 1999 (MHSWR 1999). Therefore this task has to be undertaken by a crew manager or above.

8.45 Robust annual training for all crew managers and above needs to be provided on carrying out a risk assessment on the incident ground.

8.46 The command support function was not operating effectively at the incident and this needs to be addressed urgently.

8.47 WFRS should review and update S.O. 01.02.21 Incident Command System with regards to the command support function to reflect current fire service national guidance and best practice.

8.48 WFRS needs to design and purchase a suitable command and control vehicle for use in the command support function as per fire and rescue service national guidance and best practice.

8.49 Robust training needs to be provided on command and control for firefighters, crew and watch commanders and flexi-duty officers who will mobilise with the vehicle.

8.50 WFRS should introduce a structure for the correct level of management support commensurate to the size and complexity of an incident for the command support function.

8.51 Robust training needs to be provided on the command support function to all firefighters and incident commanders.

8.52 The role of sector commanders needs review and updating.

8.53 WFRS needs to review and update S.O. 01.02.21 Incident Command System with regards to sectorisation and sector commanders to reflect current fire and rescue service national guidance and best practice.

8.54 Robust training needs to be provided for all firefighters and incident commanders on sectorisation of an incident and the importance of maintaining command restraint in a pressured environment.

8.55 The incident revealed serious deficiencies in resources and this vital issue needs to be addressed.

8.56 WFRS needs to review and update S.O. 01.02.21 Incident Command System to ensure that sufficient resources are available at the incident in a timely manner to provide safe systems of work for the risks identified.

8.57 This review should include a process for requesting assistance at an incident that ensures that, when considering making up appliances at an incident, the incident commander follows a logical thought process, as follows:

  • Consider the circumstances of the incident:
  • How many firefighters and appliances are needed to bring it under control?
  • Consider the arrival time of the last of that number:
  • What will be the circumstances of the incident at that time?
  • Will that number of firefighters and appliances still be sufficient to bring it under control?
  • If no: How many firefighters and appliances will be required to bring it under control?
  • Consider the arrival time of the last of that number of requested appliances:
  • What will be the circumstances of the incident at that new time?
  • Will that new number of firefighters and appliances still be sufficient to bring it under control?
  • If no: How many firefighters and appliances will be required to bring it under control?

8.58 Robust training needs to be provided on resourcing of an incident for all incident commanders.

8.59 WFRS needs to comply with GRA 3.1 Fighting Fires in Buildings.

Dynamic risk assessment

8.60 We recommend the following revisions be made to dynamic risk assessment (DRA) guidance nationally, regionally and within WFRS:

  • Existing FRS guidance on DRA should be revised and replaced by: a system of work that reflects decision making (HSG 48), perception of risk, and a method of recording decision making; and a system to ensure the incident commanders’ assessment of risk at the incident takes cognisance of this information.
  • Robust training will need to be provided on revised FRS guidance on DRA.

8.61 We recommend that WFRS makes the following revisions to the dynamic risk assessment process:

  • Revise and replace the existing policies, procedures, operational documents and risk assessments that use DRA as a control measure for managing risk.
  • Provide robust training for all firefighters and incident commanders on the revised and replaced policies, procedures, operational documents and risk assessments.

Breathing apparatus

8.62 It is evident that inexperienced BA wearers were nominated and allowed to be committed into the risk area to attack the fire. This was not challenged by anyone on the night. We therefore recommend that WFRS should:

  • Comply with current fire and rescue service national guidance and best practice on selection of BA team leaders and BA wearers.
  • Review S.O. 05.04.10 Development FF Helmet Markings.
  • Provide awareness training for all firefighters and incident commanders on the revised service order.

8.63 It is also evident that at the incident there was ineffective briefing and debriefing of BA teams, wearers and passage of information and recording of actions and we recommend the following changes nationally, regionally and within WFRS:

  • Introduce detailed guidance on the briefing and debriefing of all BA team members, a method of recording information, and a system to ensure the incident commander’s risk assessment of the incident takes cognisance of this information.
  • Provide robust training on briefing and debriefing of BA wearers and the method of recording information for all firefighters and incident commanders.

8.64 The report revealed confusion about naming and numbering of entry control points (ECPs) and BA teams during the incident and we recommend the following to address these issues nationally and regionally:

  • Introduce a singular system of designating BA entry control points and numbering of BA teams.
  • Provide robust training on the new system of designation of ECPs and the numbering of BA teams.

8.65 The incident revealed insufficient understanding of the effects of recommitting BA wearers with minimal rest period between BA wears and we recommend the following to be applied nationally, regionally and within WFRS:

  • Recommitting of BA wearers should only occur on exceptional circumstances (firefighters should not be recommitted on more than one occasion in any circumstances) and then must take cognisance of the recommendations below.
  • A policy and procedure should be introduced to ensure that firefighters have a sufficient period of recovery and rest between BA wears. For BA activities in ambient temperatures the recovery period should be at least 28 minutes. This should be extended to at least 65 minutes for hot fire environments.
  • Firefighters and incident commanders should be trained on identifying signs and symptoms of heat stress and recognising the need to withdraw to fresh air.
  • Water must be available for all personnel involved to replace body fluids and prevent dehydration.
  • There also needs to be a method of ensuring that BA wearers have consumed at least 1 litre of water before they are recommitted.
  • A recording mechanism should be introduced to include the names of wearers, their times of entry and exit and a brief description of the conditions and activity.
  • Robust training should be provided to ensure that all firefighters and incident commanders are aware of the risks and procedures of recommitting in BA.

8.66 Numerous BA teams were committed, but some of these teams comprised BA wearers from different stations who were unknown to each other and did not number off before entering the fire compartment. To address this issue nationally, regionally and within WFRS we recommend:

  • FRSs need to ensure that BA teams committed into a risk area are from the same station or have trained together prior to forming a BA team.
  • If BA wearers are not from the same station it must be brought to the attention of the Breathing Apparatus Entry Control Officer (BAECO) who must ensure that the team number off and that all receive the detailed brief before entering the risk area.

8.67 During the incident BA teams were entering and leaving the fire compartment with no firefighting media. We recommend the following to address this issue:

  • WFRS needs to ensure that BA teams entering a compartment or building on fire have firefighting media, with a secure water supply, as a means of protection.
  • This should be written into all related risk assessments as a control measure and included in SOPs relating to this type of incident.
  • Robust training should be provided to all firefighters and incident commanders on the procedure.

8.68 The incident revealed confusion about the function of BA main control and we recommend the following:

  • WFRS needs to comply with current fire and rescue service national guidance and best practice on BA main control procedures.
  • Robust training on BA main control procedures should be provided to firefighters and crew and watch commanders who will mobilise with the BA tender.
  • Robust training on BA main control officer duties should be provided to all officers on the flexi-duty system.
  • WFRS should include BA main control procedures training as an addition to the fire behaviour and tactical firefighting courses.

8.69 The incident revealed issues over the use of guidelines and we recommend the following measures:

  • There should be a risk-based review of the requirement for the use of guidelines within WFRS.
  • WFRS needs to comply with current fire and rescue service national guidance and best practice on guideline procedures.
  • Robust training must be provided on guideline procedures to all firefighters and incident commanders.

8.70 The incident exposed serious issues concerning the deployment of BA emergency procedures which we recommend be addressed as follows:

  • WFRS needs to comply with current fire and rescue service national guidance and best practice on BA emergency procedures.
  • WFRS should procure and place emergency air supply equipment (EASE) sets on every pumping appliance.
  • Robust training should be provided on BA emergency procedures to all firefighters and incident commanders.
  • WFRS should include BA emergency procedures as an addition to the fire behaviour and tactical firefighting courses.

8.71 The incident revealed issues concerning Stage II procedures which we recommend be addressed as follows:

  • WFRS needs to comply with current fire and rescue service national guidance and best practice on Stage II procedures.
  • Robust training must be provided on Stage II procedures to all firefighters and incident commanders.

8.72 The incident revealed issues about the content and frequency of radio communications between BAECOs and BA team leaders which we recommend be addressed as follows:

  • WFRS needs to comply with current fire and rescue service national guidance and best practice on BA radio communication procedures.
  • Robust training should be provided on BA radio communication procedures to all firefighters and incident commanders as an addition to the fire behaviour and tactical firefighting courses.

Water supplies

8.73 The incident revealed issues about pre-planning and the availability of up-to-date information regarding water supplies. The onsite water supplies were a bore hole and a 16,000 litre tank which proved to be unusable on the night. These should have been identified by the risk information process as to their suitability to assist in firefighting operations.

8.74 WFRS needs to comply with Fire Service Manual Volume 1, Fire Service Technology, Equipment and Media, Hydraulics, Pumps and Water Supplies Chapter 7 and best practice to ensure adequate water provision for its purposes at incidents. This assessment and its findings need to be implemented.

8.75 The up-to-date information contained in Aquarius 3 must be made available at all times to the incident ground.

8.76 Water supplies were given some cognisance during the incident. However, a sustainable supply was not secured in place until the deployment of the high volume pump close to 21:00 hours. A water relay or shuttle was not secured from either of the two nearest hydrants prior to the BA emergency. Appliances were ferried from the holding area to supply water to the fire ground pumps but were not replenished. This led to a diminishing supply on the incident ground.

8.77 Robust training needs to be provided to ensure all firefighters and incident commanders are aware of the hazards that may arise if a sustainable water supply is not secured in the early stages of an incident. This training must also include methods of securing a sustainable water supply e.g. water relay, water shuttle, HVP etc.

8.78 Sustainable water supplies should be written into the Generic Risk Assessment 3.1 Fighting Fires in Buildings.

8.79 There was no identified individual responsibility for securing a sustainable water supply during the initial stages of an incident from single to multi pump attendances. Water usage was not communicated to the incident or sector commanders which led to an impression that water supplies on the incident ground were sufficient. To address these issues:

  • Robust policies and procedures need to be provided, as soon as possible, to ensure that all firefighters and incident commanders are aware of their responsibilities in securing a sustainable water supply at an incident
  • Robust training must be provided to ensure all firefighters and incident commanders are aware of the need to communicate about the amount of water used and required and available at an incident.

Operations

8.80 A thermal Image camera displaying a white screen during the incident caused confusion about its operational effectiveness. Fires involving large amounts of fuel or petroleum based materials appear to affect the ability of thermal image cameras (TICs) to determine temperature change and thus provide a picture for crews operating within this type of environment.

8.81 Nationally and within WFRS training needs to be provided to all firefighters on the potential for the above situation to occur within petroleum-based materials which identifies and demonstrates various types of petroleum-based materials and its effects on thermal image cameras used in compartment fires.

8.82 Fires involving large amounts of fuel or petroleum-based materials and the effect on ability of TICs should be considered and written into the Generic Risk Assessment 3.1 Fighting Fires in Buildings (GRA 3.1).

8.83 A covering jet was not deployed before BA teams were committed into the risk area. The resources available at the early stages of the incident were limited, given the size and nature of the property. This resulted in several fundamental actions being delayed. The deployment of the covering jet was not initiated until approximately one hour after the arrival of the first appliance and prior to the fourth BA team being committed to the risk area.

8.84 WFRS needs to ensure that:

  • Sufficient resources are mobilised to all structural fire incidents which enable all safe systems of work to be applied prior to committal of BA crews into the risk area.
  • All incident commanders and firefighters are made aware of the significant risks of not deploying covering jets prior to the committal of BA teams into a risk area.

8.85 The incident revealed poor hose management. Progress for BA crews within a risk area can be severely hampered if hose lines are poorly managed, resulting in ‘a bunch of knots’ and congestion, as was the case at this incident.

8.86 WFRS needs to ensure that:

  • Firefighters are made aware of the importance of correct hose management within a risk area.

8.87 During the incident personnel were going beyond BAECO without the proper use of BA.

8.88 National operational guidance should be developed and provided to all firefighters and incident commanders on the risks of progressing beyond any BA command and control point without donning a BA set and going under air. FBU must be involved in the writing of this guidance.

8.89 All firefighters and incident commanders should demonstrate underpinning knowledge and understanding of the above national operational guidance, on annual basis, to enable them to carry out their functions safely.

8.90 The outcomes of the national operational guidance should be written into the review of GRA 3.1.

Fire development and firefighting actions

8.91 The investigation indicated that firefighters were not well trained to deal with the sudden fire growth that seems to have occurred during the incident with tragic consequences.

8.92 Firefighters continue to be trained in simulator units where fires burn at a steady state for an extended period of time. They do not replicate the sudden increase in fire intensity that is typical of modern situations. Firefighters are not taught how to identify signs and symptoms of impending sudden fire growth in different types of building/compartment and how to respond to these signs and symptoms.

8.93 Nationally and within WFRS training must be provided to all firefighters in a controlled but realistic situation which:

  • demonstrates various types of fire growth characteristics and mechanisms of fire spread and its effects on compartments of all sizes and all types of buildings;
  • demonstrates the effect that fire loading and the energy released has when involved in a compartment fire.

8.94 Fire growth characteristics and mechanisms of fire spread should be considered and written into the Generic Risk Assessment 3.1 Fighting Fires in Buildings (GRA 3.1).

8.95 To ensure consistency, national operational guidance needs to be written on fire growth characteristics and mechanisms of fire spread, which should include the outcomes of the GRA 3.1.  In order to incorporate fully all of the lessons learned from this tragic incident, both BRE Global (the independent fire certification body, Building Research Establishment) and the FBU must be involved in the writing of this guidance.

8.96 All of the above should be implemented.

8.97 The incident revealed the dangers inherent in incomplete fire safety systems.

8.98 Firefighter safety does not rely on building design but on adequate firefighter training and appropriate equipment delivered to the incident ground at the right time.

8.99 Building standards throughout the UK call for ‘facilities for the fire and rescue service’ to be provided in certain buildings, but these standards do not extend any further than fire appliance access to the perimeter of buildings and firefighting shafts in tall buildings.

8.100 Even these are only provided to assist firefighters in the rescue of occupants in the early stages of a fire. They are not intended to assist firefighters in dealing with a well-developed fire in premises. Having said, that firefighters and incident commanders must have basic understanding of fire safety measures required in buildings. Therefore the FRSs nationally and locally need to ensure that:

  • A robust training system is provided to ensure all firefighters and incident commanders are able to identify omissions in fire safety systems as well as operational risks whilst carrying out 7.2d inspections3. (3Part 2 section 7(2)(d) Fire and Rescue Services Act 2004)
  • Fire safety audit staff are able to identify operational risks whilst carrying out inspections of fire safety systems. FRSs employing fire safety audit staff who have no operational background must consider the impact that this will have on their capacity to gather operational risk information.
  • They introduce a robust mechanism, as soon as possible, for processing and disseminating information about significant omissions in fire safety systems and operational risks.

8.101 The building construction of the Wealmoor premises was typical of large compartment warehouses. In rural areas firefighters may not have experience of dealing with fires in these types of buildings.

8.102 As the industrial landscape of the country changes, the construction of large compartment warehouses has moved out of town to large plots of land closer to motorway routes and trunk roads.  This has put them into the station areas of rural fire stations and retained duty system firefighters, who typically do not have experience of fighting fires in these types of building. It is widely known that knowledge of the modern built environment is inadequate amongst operational firefighter and incident commanders. Therefore FRSs nationally and locally need to ensure that:

  • A robust training system is provided to ensure all firefighters and incident commanders have current knowledge of all types of building construction.
  • A robust training system is provided to ensure all firefighters and incident commanders have current knowledge of how fire develops, signs of fire and the effects on all types of building construction, i.e.:
  • A compartment’s ability to lose heat will decrease so the fire needs to produce less energy to create flashover conditions.
  • Fewer external signs of fire such as smoke and flames issuing from openings and joints, firefighters and incident commanders are therefore less able to predict internal conditions from external appearances.
  • A robust training system is provided to ensure all firefighters and incident commanders fully understand search and firefighting techniques in large compartments, by utilising practical and theoretical sessions.
  • Robust training is provided to ensure all firefighters and incident commanders are aware of the hazards associated with plastic and PVC cable trunking and conduit used to secure electric cabling failing at relatively low temperatures.
  • They provide suitable equipment for BA teams to enable wearers to free themselves and other BA wearers from cable entrapment and that robust training is provided to ensure all firefighters are competent in use of this equipment.
  • They introduce a robust process that demonstrates practically that all firefighters and incident commanders have gained underpinning knowledge and understanding of the above, on an annual basis, to enable them to carry out their functions safely.
  • The hazards identified with buildings of this nature in the investigation process are shared and written into the Generic Risk Assessment 3.1 Fighting Fires in Buildings.
  • They have an audit and review process to ensure that policies and procedures implemented are current and ensure competence of firefighters.

8.103 There needs to be more training on firefighting actions in large compartments and research undertaken on how best to manage fire behaviour in such situations.

8.104 Gas cooling has become a common firefighting practice in the fire and rescue service. The principle is that, using a hose-reel jet, short bursts of water spray into the hot ceiling gases of a compartment fire to cool those gases and thereby reduce the risk of flashover and improve conditions for firefighters.

8.105 Awareness training needs to be provided to ensure all firefighters and incident commanders have the knowledge and understanding of the hazards associated with firefighting in large compartments. In large compartments gas cooling by short bursts of water spray from a hose-reel branch may have no noticeable effect on the ceiling gas temperature, but it is likely to increase humidity. As humid air is a better conductor of heat than dry air, gas cooling in a very large compartment on fire may not cool fire gases, and is unlikely to reduce the risk of flashover, but may worsen conditions for firefighters and any others who may be present.

8.106 As the number of fires in the UK continues to fall, non-carbonaceous fire training, carbonaceous fire training in small, otherwise empty, compartments and real fire training comprising fires contained in metal cribs, have to compensate for a lack of real-life firefighting experience of firefighters on station. Firefighters have less and less personal experience of real fire behaviour – especially those based at more rural stations.

8.107 The FBU is of the opinion that there is an overemphasis in UK FRS training on the process called ‘flashover’ and therefore recommends that:

  • Research is undertaken on how to manage fire behaviour and firefighting techniques in large compartments to include the correct hose diameter and discharge rate, both to protect firefighters and control the developing fire. The outcomes of the research should be published and written into the Generic Risk Assessment 3.1 Fighting Fires in Buildings.

General

8.108 A robust process needs to be introduced that demonstrates practically that all firefighters and incident commanders have gained underpinning knowledge and understanding of all the above recommendations, on an annual basis, to enable them to carry out their functions safely.

8.109 There needs to be an audit and review to ensure that all policies and procedures implemented are current and ensure competence of firefighters and the WFRS training framework must provide, record and ensure competence of all firefighters.

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

--end--

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

Warwickshire Fire and Rescue Service (WFRS). (unknown date). Report on the fire at Atherstone on Stour, 2nd November 2007. [pdf] Available at https://apps.warwickshire.gov.uk/api/documents/WCCC-954-385 [Accessed 12th July 2016].

FBU Incident Report/s

The Fire Brigades Union (FBU). (unknown date). Fatal Accident Investigation – Summary report into the deaths of Ian Reid, John Averis, Ashley Stephens and Darren Yates-Bradley at Wealmoor (Atherstone) Ltd, Atherstone on Stour, Warwickshire. [pdf] FBU Warwickshire Summary Report FBU Warwickshire Summary Report.  FBU Warwickshire Summary Report.  FBU Warwickshire Summary Report.

The Fire Brigades Union (FBU). (unknown date). Fatal Accident Investigation – Full report into the deaths of firefighters John Averis, In Reid, Ashley Stephens and Darren Yates-Bradley at Wealmoor (Atherstone) Ltd, Hangers 1 and 2, Atherstone Industrial Estate Atherstone on Stour, CV37 8BJ. [pdf] Atherstone FBU Report Full Redacted.  Atherstone FBU Report Full Redacted Available here.

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

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

Warwickshire Police Incident Report/s

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

West Midlands 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

No information identified to date and/or 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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