Incident directory

1996 - Blaina

01/02/1996

Country:

UK

  • Building Fires

Severity:

Fatal

Description

Date of event

1st February 1996                 

Time of event

06:03 HRS (INITIAL CALL)

Name of premises

14 Zephaniah Way

Location

Blaina, Gwent

Service area

Gwent Fire Brigade (now South Wales Fire and Rescue Service (SWFRS))

Nature of incident

Fire

Property type

2 storey mid house.

Premises use

Domestic dwelling.

Construction type and materials

Concrete block, brick over a concrete ground floor and under a slate roof. Stud partitions and timber flooring within.

Occupancy

1 female adult, 2 male children

Fire source and location of fire

Origin of fire in kitchen at rear of property, exact cause was recorded in Brigade Fire Investigation Report as "Unknown". Smoking materials, utilities, arson and cooking appliances were ruled out as a cause.

Synopsis

Brief Synopsis

At 06:03:19 on the 1st February 1996, Gwent Fire Brigade received a call to a fire at 14 Zephania Way, Blaina. Initially 1 pumping appliance, B031, was sent as per brigade policy at the time of the fire and booked mobile at approximately 06:08. There was conflicting information from the incident given to control as to whether there were persons within the property and this was subsequently passed onto the initial attending appliance. The pre-determined attendance (PDA) was increased to 2 pumps by control due to the number of repeat calls and information that indicated children were inside the property. The second pump, B021, booked mobile at approximately 06:14 (Pearson & Allen, 1996).

On arrival (at approximately 06:10) the officer in charge (OIC) of the first pump, B031, was informed by control that the incident was in fact persons reported with an unspecified number of children reported trapped. A breathing apparatus (BA) crew of two entered the property, with a hose reel, through the front door and rescued a young boy who was later pronounced dead on arrival at hospital. A large crowd had gathered outside (Pearson & Allen, 1996).

On receiving incorrect information that another child was trapped upstairs the firefighters returned into the property. One firefighter had broken the seal of his BA mask between entries. As they attempted to reach the first floor at approximately 06:14 a rapid fire development occurred (described as backdraft and/or fire gas ignitions with subsequent flashover) with enough intensity in the blast to slam the front door onto the hose reel, jamming the door and blocking both the firefighters egress. The firefighters became engulfed in flames. Two further firefighters attempted to rescue their colleagues. The jammed door initially prevented rescuers from entering (Pearson & Allen, 1996).

Initial publications including the FBU Fatal Accident Investigation reported the incident was caused by a backdraught, but others such as Grimwood (1998) have since suggested that a fire gas ignition could in fact have caused the blast.

Two possible explanations have been offered for the incident and both are described by Grimwood (1998).

  1. Flammable gasses built up on the upper floor and ignited when the ceiling burnt through introducing a heat source - Fire Gas Ignition
  2. Flammable gasses built up on the upper floor in an under-ventilated compartment and when the front door was opened this introduced an air track/pathway leading to a backdraught.

 Front page graphic HW crop 636349343557142668

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Fig 3 (1)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Fig 7 (2)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

 Fig 8 (3)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Fig 9 (4)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Fig 10 (5)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Plate 2 (6)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Plate 10 (7)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU). 

(8)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Plate 3 (9)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Plate 4 (10)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

(11)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

(12)

Photographs courtesy of  the South Wales Fire and Rescue Service (SWFRS) and the Fire Brigades Unions (FBU).

Main findings, key lessons & areas for learning

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

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

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

FBU summary of main findings, key lessons & recommendations

Taken from: Fire Brigades Union (FBU) Incident Report.  Pearson, D. & Allen, B. (circa 1996).  Fatal Accident Investigation, 14 Zephaniah Way, Blaina, Gwent, 1st February 1996: Report and Conclusions.

--subaccordion--

13. TRAINING

The conclusions made in this report with regard to the training of the personnel who attended the incident are divided into two sections:

a) TRAINING OF THE CREWS

b) TRAINING OF THE OFFICER-IN-CHARGE

a) Training of the crews.

13.2 There would undoubtedly be a "moral pressure" on the initial crew attending the incident to attempt a snatch rescue from the house before undertaking any firefighting duties, given the circumstances with which they were presented on arrival. This they did successfully in the first instance, notwithstanding the considerable risk this course of action placed the BA crew in when they made their initial entry. The risk was minimised to a point by the wearing of breathing apparatus sets and fire kit and by the fact that the crew took a hose reel with them into the house, in line with their training (paragraph 4.20). The Officer-in Charge also sent an assistance message to Control to provide the additional resources in terms of manpower and equipment which it was apparent to him would be required for firefighting and safety procedures to be put into place, given the priority of action decided upon in terms of rescues (paragraph 4.22).

13.3 Notwithstanding the fact that several indicators of a potential backdraught were present on arrival at the incident, it would be unrealistic to suggest that the initial crew attending would have done anything other than to enter the house on arrival to search for casualties. The question which the incident poses is whether anything could have been done by the initial crew attending to minimise the potential for a backdraught to occur, or to reduce the risk to firefighters entering the house, given the constraints in terms of manpower under which they were operating.

13.4 The Home Office Fire Research and Development Group commissioned a survey into backdraught to be undertaken by Richard Chitty of the Fire Research Station following concerns raised as to the level of knowledge amongst firefighters about this phenomenon. The results of the survey were published in mid-1994 by the Home Office under the title "A Survey of Backdraught" - FRDG Publication Number 5/94. The report describes a survey of current knowledge of backdraught and considers needs for any further research work and the implications for the training of firefighters. The Management Summary in the report describes the conditions which may lead to a backdraught and the need for firefighters to be able to identify these conditions. The Summary also states that there is currently no practical training given to firefighters regarding backdraught in the UK. (1994).

With regard to training of firefighters the survey concludes:

13.5 All firefighters need an adequate understanding of the development of fires in both well and under-ventilated states so that they can recognise potential backdraught and flashover conditions. Tactics such as venting, indirect and offensive application of water can then be used effectively and safely.

13.6 Safety considerations make the development of realistic training facilities for flashover and backdraught difficult, if not prohibitive. However training programmes reinforcing academic fire science with small scale demonstrations and then full scale fire fighting exercises would provide a good understanding of the basic scientific principles of fire development and how various fire fighting techniques operate.

13.7 There is a clear need within the Fire Service for a sound education on all aspects of fire science. A simple book along the lines of Giselsson and Rosander's "Fundamentals of Fire " but which gives a sound introduction of the principles of fire behaviour and the mechanisms of firefighting techniques to the practising firefighter would be particularly valuable.

13.8 The subject of training has also been examined recently by the Central Fire Brigades Advisory Council. As a result of a number of expressions of concern being voiced regarding fire service training by constituent members of the Joint Training Committee of the CFBAC a two day seminar was held at the Fire Service College in October 1992 which resulted in the formation of the Training Strategy Group (TSG). The TSG was tasked to consider fire service training in the widest context, throughout a firefighter‘s career, for each post and every rank, and with the following terms of reference:

13.9 To analyse the selection, training and development needs of the fire service both long and short term, to identify the problems and make proposals for action.

13.10 The report of the Training Strategy Group was published in August 1994 and accepted by the CFBAC. An Implementation Working Group was subsequently established and charged with taking forward the Training Strategy. One of the areas considered by the TSG was operational training. Paragraph 4.5.4 of the report states:

13.11 In examining the current education and training of firefighters in the fire sciences and behaviour of fire, we believe there are serious deficiencies which must be addressed if firefighters are to be competent and safe in the performance of their job. With the increasing range of complex incidents attended by the fire service, the opportunity for experiential learning in all aspects of a firefighters role can no longer be guaranteed. The provision of appropriate training for all firefighters, whole-time, retained or volunteer, is vitally important. Modem protective clothing and breathing apparatus allow firefighters to venture into situations at operational incidents which may put them at potentially greater risk. Firefighters must be able to recognise the dangers and risks involved. Accordingly:

13.12 We RECOMMEND that greater emphasis be placed upon a firefighter’s education and training in the fire sciences and behaviour of fire.

13.13 Coupled with the wisdom of that knowledge must be the development of suitable facilities to demonstrate the characteristics of combustion and fire behaviour and allow firefighters to learn and practise safe and effective tactical techniques to extinguish fire. We recognise practical training facilities are expensive and provision on a collaborative basis must be examined more objectively.

13.14 We RECOMMEND that with in five years sufficient practical training facilities must be provided to enable all firefighters to receive basic and continuation training using real fire training techniques and procedures.

13.15 A supplement to the Manuals of Firemanship in line with the suggestion in the FRDG report was printed by the Home Office in January 1995. The supplement entitled "The Behaviour of Fire - Compartment Fires" ran to a third impression by July 1995 due to demand by fire brigades in the U.K. However due to the financial constraints on Fire Authorities the development of training programmes as suggested by FRDG or practical training facilities as recommended by the TSG have been extremely limited and localised.

13.16 Gwent Fire Brigade issued the supplement to the Manuals of Firemanship to stations in October 1995 however the information on backdraughts contained in the supplement was not supported by a training package. Neither was the Brigade Whole-time Training Programme or Quarterly Retained Firefighter Drill Programme updated in order that the information could be brought to the attention of firefighters in a structured format. There was no real fire training provided in line with TSG recommendations albeit that the Brigade was due to cease to exist as a consequence of Local Government Re-organisation (LGR) effective 1st April 1996. Consequently the development of training packages or real fire training in backdraught or flashover would arguably have been seen as a remit of the soon to be formed South Wales Fire Brigade given the time constraints under which Gwent was operating in terms of LGR.

13.17 The Brigade Quarterly Retained Firefighter Drill Programme did require that once a year a lecture was to be given on "Ventilation" although there was no reference to any supporting bibliography which should be used as a reference for retained Junior Officers in preparing the lecture. The contents of the Manual of Firemanship Book 12 Chapter 10 would generally have been used as the basis for the lecture which apart from one paragraph on smoke explosions, deals with the value of ventilation in terms of preventing and reducing smoke damage and fire spread, assisting firefighters in terms of locating and attacking the fire, and practical methods of removing smoke from premises. The paragraph on smoke explosions does warn firefighters of the serious risk which may exist when flammable smoke and vapours collect in an enclosed space and are subsequently mixed with air. It makes reference to foamed rubber in particular as a material which can produce this flammable smoke, potentially leading to a smoke explosion. However the text does not use the term backdraught, is extremely basic in terms of indicators of a smoke explosion and concludes that:

13.18 Firemen should take particular care to protect themselves from any possible blast wave, e.g. by avoiding the front of openings and keeping close to the floor.

13.19 Gwent Fire Brigade did include an item in their Technical Information and Procedures (TIP) file on the "Explosion Risk of foamed Rubber" which elaborated on the information given in Book 12 Chapter 10. A revised TIP on the subject was issued to stations in July 1990 however the TIP stated that:

13.20 In broad terms, the deflagration of accumulated flammable vapours is unlikely to take place except in a closed compartment of relatively small size. A bedroom," living room or small storeroom, whose door or windows were neither open or broken might lead to a hazardous condition, which is unlikely to exist in a small area of a large warehouse or factory compartment.

13.21 The TIP deals specifically with foamed rubber as a source of flammable smoke and suggests ventilation as a means of reducing the hazardous conditions these enclosed smouldering fires create. It suggests further reading, the Manual of Firemanship Book 6A Chapter 32 Section 8 (sic) and Chapter 37 Section 3 and 4 which deal with ventilation and have been replaced by the Manual of Firemanship Book 12 referred to above. There was no specific requirement in the Brigade's Quarterly Retained Firefighter Drill Programme to use TlP's as a reference source for continuation training of personnel and no cross references to TIP's relevant to any particular training session required under the programme. The use of information contained in TIP's in any quarterly retained training session would have been dependant on the retained Junior Officer remembering the existence of TlP's relevant to the subject heading given in the Drill Programme.

13.22 The Brigade's Initial Breathing Apparatus Course, given to firefighters to train them in the correct procedures to be adopted when wearing breathing apparatus, did not cover backdraughts or the indicators of potential backdraughts in the syllabus. Similarly Breathing Apparatus Refresher Courses, required to be undertaken by all qualified breathing apparatus wearers every two years, did not include backdraught training.

13.23 Whether or not training could have prevented the delayed backdraught occurring at the incident is open to debate. There appear to have been two possible options open to the initial crew attending to minimise the risk to the firefighters committed to make the snatch rescue. Firstly the venting of the premises to remove the fire gases by the opening or breaking of windows at ground and first floor levels or secondly by making an attack on the fire in the kitchen from the rear of the premises to prevent an ignition source from reaching the fire gases. The decision to take either or both of these preventative measures would have been dependant on the crew of the Blaina fire appliance recognising the indicators present at the incident for a potential backdraught to occur, and subsequently re-deploying their limited resources in terms of manpower in an attempt to prevent the occurrence.

CONCLUSION

13.24 The crews attending the incident had not been provided with specific structured training in how to recognise the indicators of a potential backdraught and the tactics to reduce the risk of the backdraught occurring. Training in terms of lectures on ventilation, required under either the Quarterly Retained Firefighter Drill Programme or the Whole-time Firefighter Training Programme operating in Gwent, provided the crews with little information on backdraughts, and was not, in the case of retained firefighters, supported by any references to a bibliography to be used in the preparation of lectures. There was no practical training given to crews in backdraught recognition or firefighting techniques.

b) Training of the Officer-in-Charge.

13.25 Regulation 3 of the Management of Health and Safety at Work Regulations 1992, made under the Health and Safety at Work Act 1974, places the following duty on employers:

(1) Every employer shall make a suitable and sufficient assessment of:

(a) the risks to the health and safety of his employees to which they are exposed whilst they are at work; and

(b) the risks to the health and safety of persons not in his employment arising out of or in connection with the conduct by him of his undertaking,

for the purpose of identifying the measures he needs to take to comply with the requirements and prohibitions imposed upon him by or under the relevant statutory provisions.

13.26 Regulation 8 (part) of the Management of Health and Safety at Work Regulations 1992 states:

Every employer shall provide his employees with comprehensible and relevant information on-

(a) the risks to their health and safety identified by the assessment;

(b) the preventive and protective measures;

13.27 At an incident the senior fire brigade officer in attendance is responsible for the health and safety of the personnel under his or her command. In the case of the incident at 14 Zephaniah Way, Sub Officer 1 (Blaina fire appliance OIC) could not carry out a suitable and sufficient assessment of the risks to the health and safety of the crew under his command as he had not received adequate training which would allow him to recognise the indicators of a potential backdraught. Consequently he was not in a position to instigate the necessary preventive and protective measures to minimise the risk to the BA crew who were subsequently caught in the backdraught.

CONCLUSION

13.28 The Officer-in-Charge of the initial attendance was not in a position to carry out a suitable and sufficient risk assessment of the dangers to his initial BA crew due to inadequate training in regard to the recognition of indicators of a potential backdraught. Consequently he would not have been in a position to instigate appropriate preventive and protective measures to minimise the risk to that BA crew.

BREATHING APPARATUS PROCEDURES

14.1 Gwent Fire Brigade operated breathing apparatus procedures in line with Technical Bulletin 1/ 1989 - Breathing Apparatus (TB 1/89). The crews of both the Blaina and Abertillery fire appliances had received practical training in breathing apparatus procedures in the form of an initial Breathing Apparatus Wearer‘s Course and periodic Breathing Apparatus Refresher Courses which were run internally by the Brigade.

14.2 The incident at 14 Zephaniah Way calls into question some of the suggested procedures in Technical Bulletin 1/1989 and highlights shortcomings as regards those procedures where Stage 1 Breathing Apparatus Entry Control is set up.

14.3 When the Blaina crew arrived at the incident at 06.09 hours and 59 seconds they were confronted with a situation which required immediate action in tenns of rescues if the occupants of the house were to stand a chance of survival. The BA team, who had begun donning their sets en-route to the incident, proceeded to the front of the property immediately and became self-contained in order to effect a snatch rescue (paragraph 4.20). Consequently the setting up of Stage 1 Entry Control as laid down in TB 1/89 did not take place. The procedure (part) laid down in TB 1/89 for implementing BA Stage 1 Entry Control is as follows:

17. DUTIES OF BA WEARERS AT AN INCIDENT

(1) Firefighters ordered to wear breathing apparatus at an incident are responsible for:

(b) handing the tally to the entry control officer before entering the risk areas.

23. DUTIES OF ENTRY CONTROL OFFICERS (STAGE 1)

(1) The duties of the Stage I Entry Control Officer at each entry control point h:

(a) providing an entry control board and suitable waterproof marker, and providing and wearing a breathing apparatus control tabard;

(b) taking up the position nominated by the officer-in-charge for the entry control point,-

(c) indicating clearly on the entry control board that Stage I is in operation;

(d) receiving the tallies of breathing apparatus wearers and checking that the name of the wearer and cylinder content at the time of entry into the risk area are correctly recorded;

14.5 Although it is not disputed that these procedures, if followed correctly, provide an adequate level of control over firefighters in breathing apparatus entering and leaving a risk area, firefighters feel a moral obligation at certain incidents to act immediately where life is threatened and rescues are required. This is particularly true when children are involved.

14.6 The requirement to set up a Stage 1 Entry Control Point, to hand in BA tallies at the Stage 1 Entry Control Point and the checking of the cylinder contents and the wearers name by the BA Entry Control Officer prior to the BA crews entering the risk area, increases the time it takes to enter the property. Where a fire appliance initially attends a "persons reported" call and no BA Entry Control Point is in existence, firefighters are placed in a position where they must either delay their entry to the risk area in order to carry out the required entry procedures, or as more often happens, not comply with the requirements of the entry procedures as laid down in TB 1/89. This facilitates a faster entry and consequently increase the chances of effecting a successful rescue with improved chances of survival for the rescued person(s).

14.7 The entry control procedures in TB 1/89 do not take into account the decision which firefighters often take, based on the prevailing circumstances on arrival, to effect a "snatch rescue" at an incident. If the initial crew attending an incident decide to attempt a snatch rescue then it is not unusual for Stage 1 Control to be set up after the BA crew has entered the risk area. The BA Entry Control Officer is then placed in a position where he/she is unsure of the actual "Time In" to be recorded on the BA tally, and must make an estimate of the time of entry of the BA crew.

14.8 As stated, a BA Stage 1 Entry Control Point was not set up at 14 Zephaniah Way in line with TB 1/ 89. This lead to inaccuracies in the details recorded on the BA control board when the details of the BA crews were filled in. L/ff 1 (B031) had started to record details on the BA board, which he had placed at the rear of the appliance on arrival (paragraph 4.18), however he had also been responsible for operating the pump and sending messages from the incident to Control. These messages, requesting additional resources at 06.11 hours and 18 seconds and confirming that an ambulance had been mobilised to the incident at 06.14 hours and 28 seconds, were of an urgent nature and L/ff 1 adjudged the sending of them to take precedence over the completion of the entry details on the board. The BA tallies were not handed to him by the BA crew prior to them making an entry and consequently he had to estimate the cylinder contents for the wearers and the time at which they made their entry. The details recorded by him on the board were an estimated time of entry of 06.00 hours and estimated cylinder contents of 200 bars for both wearers. He had written these details on the board across the empty tally slots but had not completed the wearers names, time of whistle or location of team. L/ff 1 left the BA board and donned BA himself at 06.15 hours and 45 seconds to attempt to rescue the BA crew who were caught in the backdraught (paragraph 4.40).

14.9 When resources became available for a new BA Entry Control Officer on the arrival of the fire appliance from Abertillery, the BA board showed only two wearers as being committed to the risk area, with no tallies in the board and no names of the wearers. The new BAECO, Ff 6 ), entered details of the B021 BA crew who were to be committed to effect a rescue of the occupant of No. 16 Zephaniah Way. Having done this Ff 6 approached Sub Officer 1 (B021) to ascertain the names of the Blaina BA crew shown on the BA board. Sub Officer 1 informed him that the crew shown as being committed on the board were Ff K Lane and Ff S Griffin (paragraph 4.55). Ff 6 added these details to the entry which L/ff 1 had started and calculated the time of whistle for this crew as being 06.35 hours.

14.10 Ff 6 remained unaware that there was a third BA crew committed at the incident until after the rescue of Ff Lane and Ff Griffin. This third crew comprised L/ff 1 and Ff 1 (B031) who had entered No 14 Zephaniah Way to attempt the rescue of their colleagues (paragraph 4.45). No entry details for this crew were ever made on the BA board

14.11 The BA crew consisting of L/Ff 1 and Ff 1 were essentially assuming the role of a BA Emergency Team. In regard to the provision of emergency teams, TB 1/89 (part) states;

EMERGENCY TEAMS

(1) Emergency teams of breathing apparatus wearers are established at all incidents where Stage 2 breathing apparatus entry control procedures are in operation and at other incidents where personnel resources permit.

(7) The Entry Control Officer will deploy the emergency team in the following circumstances:

(a) where a breathing apparatus team or wearer fail to return to the entry control point by the calculated ’time of whistle’ ; or

(b) where contact with a breathing apparatus line communications team is lost without warning; or

(c) where a distress signal unit is reported operating or

(d) in any other circumstances appearing to require their deployment.

14.12 The initial attendance mobilised to the incident could not provide adequate personnel resources to establish a BA emergency team to stand-by at the Entry Control Point. This lead to a delay in the entry of a BA crew to undertake the rescue of Ff K Lane and Ff Griffin The committal of personnel from the initial appliance attending the incident to assume the role of the BA emergency team left no Breathing Apparatus Entry Control Officer at the incident and when the BA board was completed by personnel from the second appliance attending, there was no hand over of BAECO responsibility resulting in the omission of details of one BA crew from the BA board altogether.

CONCLUSION

14.13 The suggested procedures laid down in Technical Bulletin 1/89 regarding the setting up of Stage 1 BA Entry Control prior to committing BA wearers to the risk area do not take into account the moral pressure on firefighters to act quickly when the initial appliance attending an incident is faced with a "snatch rescue" situation. This can lead to Stage 1 BA Entry Control being set up after the BA crew has been committed with consequent room for mistakes to be made in the recording procedures for the time of entry of that BA crew.

14.14 The requirement for BA Emergency Teams to be established when Stage 1 BA Entry Control is in operation, only if personnel resources permit, has implications for the weight of attack initially mobilised to incidents. An initial mobilisation of two fire appliances to the incident at 14 Zephaniah Way would have provided the personnel resources necessary to establish a BA emergency team at the incident prior to the backdraught occurring. This would have facilitated a faster committal of BA personnel to effect the rescue of the firefighters caught in the backdraught.

STANDARDS OF FIRE COVER

15.1 The Consultative Document on Future Fire Policy, published in June 1980 by the Home Office, suggested that there was a need for a national review of standards of fire cover. In February 1981, the Central Fire Brigades Advisory Councils for England and Wales and for Scotland agreed that the appropriate machinery for such a review would be a Joint Committee of the Councils.

15.2 The first term of reference agreed by the Advisory Council was to consider suggestions for changes to the guidance on standards of fire cover, as set out in Fire Service Circulars 43/1958 and 23/1974, and Scottish Fire Service Circulars 934/1958 and 14/1974. The Committee met on 12 occasions between July 1981 and October 1984 and presented it's report to the CFBAC on the 24th November 1984. The report, which ran to some 56 pages, made recommendations to the Central Fire Brigades Advisory Council and the Home Secretary on the minimum numbers of fire appliances which should be mobilised in the first instance to a fire and minimum attendance times for those appliances based on the risk category of the area in which the fire occurred.

15.3 Fire Service Circular 4/1985, published on 22nd May 1985 by the Home Office, stated that the Home Secretary had received the report of the Joint Committee on Standards of Fire Cover and accepted it's recommendations. The Home Secretary recommended the adoption of the standards set down in the report to Fire Authorities who subsequently carried out the review procedure laid down in the report.

15.4 The recommendations of the Committee in terms of minimum attendances and minimum attendance times may be summarised as follows:

Risk Category

No. of Pumps in Attendance

Approximate Time Limits for Attendance (in minutes)

 

1st

2nd

3rd

‘A’

3

5

5

8

‘B’

2

5

8

-

‘C’

1

8-10

-

-

‘D’

1

20

-

-

High Risk

Predetermined Attendance

 


15.5 With regard to areas categorised as ‘C’ risk the Committee considered that Fire Authorities should review attendance policies to determine whether and if so to what extent, parts of the 'C' risk area should attract an enhanced attendance of two fire appliances with the second appliance aiming to arrive as soon as realistically possible after the first. The review of attendance policies should take place in the light of a general review of risk categorisation of areas on the basis of updated guidelines which were recommended by the Committee. The revised prose for 'C' Risk Areas in the Committee's report, page 22 Annex A, is as follows:

RISK CATEGORIES: REVISION OF THE PROSE DESCRIPTIONS IN THE HOME DEPARTMENTS’ CIRCULARS OF 1958

Category C Risk

Category C risk areas are normally to be found in the suburbs of the larger towns and the built-up areas of smaller towns. For an area to be classified as C risk it should contain built-up areas of substantial size, where the risk of life loss or damage to property in the event of fire is usually low, although in certain areas the risk of death or injury may be relatively high. Concentrations of property may vary, but will generally be of limited extent. Examples of such areas might include:

(i) Developments of generally post-war housing, including terraced and multi-storey dwellings, deck access housing and blocks of flats.

(ii) Areas of older, generally pre-war, detached or terraced multi-storey dwellings, with a predominance of property converted for multiple occupation. Areas of suburban terraced, semi-detached and detached residential properties.

(iv) Mixed low-risk industrial and residential areas.

(v) Industrial or commercial areas of smaller houses where there are few higher-risk occupancies.

15.7 The revised prose descriptions of risk categories were intended to provide a starting point for an examination of part or the whole of a brigade area in general terms. To accurately assess the appropriate risk category to be assigned to that area the use of a formula was recommended by the Committee. The formula was designed to assist with calculating the potential risk category of individual premises within an area. The formula would be used to determine the points rating, or fire grading of particular premises on the basis that a tally of 16 points or above is a potential category 'A' risk, 11 to 15 points is a potential category ‘B’ risk and 10 points and below is category 'C' or 'D' risk.

The Committee stated that the formula should not be regarded as providing an automatic decision as to the categorisation of a specific area but rather should be seen as a detailed guide, which would help standardise and refine the interpretations and application of the prose descriptions of risk categories. The formula awarded points to individual premises based on:

1) Building Density

2) Building Construction

3) Number of Storeys

4) Occupancy Rating - High, Medium or Low

A low occupancy rating was given to housing of high quality with a low occupancy.

15.8 In the study carried out by the Committee in determining the weight of attendance at 'C' risk fires it was recommended that no change should be made in the nominal attendance unless felt appropriate in the light of the general review of categorisation.

15.9 14 Zephaniah Way, Blaina was a modern mid-terraced two bedroom residential property and consequently, based on the risk categorisation formula recommended by the Committee would attract an attendance commensurate with 'C' risk i.e. one fire appliance to attend within 8/10 minutes.

15.10 The Brigade mobilising procedure set out in Brigade Orders Section 5.1.7. – Initial Attendances to Fires and Notification of Officers - complies with the minimum standards recommended in the Joint Committee Report regarding initial weight of attack at property fires. Section 5.1.7. of this order is reproduced below:

5.1. 7. Initial Attendances to Fires and Notification Officers

(a) First Attendances to Incidents will be made as follows:

IMMEDIATE ACTION

Type of Fire/Incident Appliances

First Attendance

PERSONS REPORTED 2 Wrl, (or WrT)

IMMEDIATE ACTION

SECONDARY ACTION

 

Type of fire/incident

Appliances first attendance

Officers mobilised

Officers informed

Principle officer

Inform

 

PERSONS REPORTED missing or trapped

 

2 Wrl, (or WrT) or PDA if greater

Stn. O.

Duty ADO.

Duty Officer

Duty PO

Police & Ambulance

HOUSE & RESIDENTIAL CARAVAN FIRES

‘B’ Risk area

2 Wrl (or WrT)

Stn. O.

Duty ADO.

-

Police

‘C’ & ‘D’ Risk area

1 Wrl (or WrT)

Stn O.

Duty ADO.

 

Police

15.11 The increase in the initial weight of attack to 2 fire appliances for house and residential caravan fires in ‘C’ and 'D' risk areas where persons are reported trapped is over and above that required under the 1985 Standards of Fire Cover Report recommendations.

15.12 Accordingly when the initial call for the house fire at 14 Zephaniah Way, Blaina was received the Brigade mobilised an initial predetermined attendance of one fire appliance. The call was connected to the Gwent Fire Brigade Control Room by British Telecom at 06.03 hours and 19 seconds. The fire brigade control operator ascertained from the caller that the incident was a house fire and that everyone was out of the property. Based on this information the control operator operated the turnout system for Blaina Fire Station at 06.04 hours and 20 seconds (paragraph 4.3).

15.13 In line with Brigade procedures for the mobilising of reinforcing appliances over and above the predetermined attendance based on risk categorisation of an area, the control operator mobilised a second appliance to attend the incident following a repeat call from a member of the public who stated that there were persons reported to be in the property on fire. The next nearest appliance was located at Abertillery Fire Station and the turnout system for this station was operated at 06.09 hours and 58 seconds (paragraph 4.13).

15.14 The fire appliance mobilised to the incident from Blaina Fire Station booked in attendance at the incident at 06.09 hours and 59 seconds. The fire appliance mobilised to the incident from Abertillery Fire Station booked in attendance at the incident at 06.19 hours and 46 seconds. From the brigade witness statements and digital voice operated logging tape the time at which the delayed backdraught occurred has been estimated as being 06.15 hours and 45 seconds.

15.15 The accuracy with which the time of the backdraught has been pinpointed is based on the witness statement of L/ff 1, the driver of the Blaina fire appliance, who had just completed a message to Control requesting confirmation that an ambulance had been mobilised to the incident (0615.41) and was making his way to the rear of the appliance to complete the BA board details when he became aware of a 'whoosh' from the house (paragraph 4.36).

15.16 The fire appliance mobilised to the incident from Abertillery Fire Station took 9 minutes and 48 seconds to get to the incident. If both appliances had been mobilised to the incident on receipt of the initial call for the incident i.e. at 06.04 hours and 20 seconds then the second appliance would have arrived at the incident at 06.14 hours and 8 seconds, approximately 1 minute and 37 seconds before the backdraught occurred. This additional appliance would have provided the manpower to either facilitate an attack on the fire prior to the Blaina BA crew re-entering the property to attempt a second rescue, or to initiate venting operations in the property to remove the accumulated flammable gases. It could certainly have provided the manpower for a BA emergency team to standby in line with the procedures laid down in Technical Bulletin l/89 - Breathing Apparatus - paragraph 31, which the Brigade used as the basis for it's breathing apparatus training.

15.17 At the time the backdraught occurred, the crew members of the Blaina fire appliance were engaged in the following duties:

* Sub Officer 1 was resuscitating a child casualty rescued by the BA crew (paragraph 4.3 8).

* L/ff 1 had just passed a message to Control and was proceeding to the rear of the appliance to resume his duties as BA Entry Control Officer and pump operator (paragraph 4.36).

* Ff 1 was assisting with the resuscitation of the child casualty (paragraph 4.37),

* Ff 2 was attempting to raise the occupant of the No. 16 Zephaniah Way who was reported as being trapped in a smoke-logged house (paragraph 4.39).

15.18 The question which this incident raises in regard to the weight of attack of initial attendances to property fires in 'C' and 'D' risk areas as laid down in the Central Fire Brigades Advisory Council Report of the Joint Committee on Standards of Fire Cover 1985 is to what extent firefighter safety was taken into account in recommending these minimum attendances? The Report included a Study of Working Patterns at the Scene of Incidents in an attempt to:

determine the capabilities of current appliances under different crewing arrangements, with a view to suggesting the optimum fire fighting unit for different classes of situation (para 3. I 1)

however the Committee found it difficult to arrive at an agreed view on the significance to be attached to the findings of the study and decided not to rely on the study in coming to conclusions. The study did however recognise that:

the longer travelling times in the lower risk category areas generally implied that fires in these areas would be more fully developed by the time the first attendance appliance(s) arrived (para 3.15)

15.19 The recommended one pump attendances and minimum attendance times in ‘C’ and ‘D’ risk areas have always been of concern to firefighters in that they are provided with less resources to fight more fully developed fires with reinforcements generally taking longer to arrive than at fires occurring in 'A' and 'B' risk areas.

CONCLUSION

The recommended minimum attendances and minimum attendance times as laid down in the 1985 CFBAC report on Standards of Fire Cover are weighted more in favour of limiting the spread of fire as opposed to ensuring that the safety of firefighters making up the first attendance at these incidents is not jeopardised by the initial mobilisation of insufficient resources. In the case of the incident at 14 Zephaniah Way, Blaina, an initial mobilisation of two appliances on receipt of the first call to the incident would have provided an additional crew at the fire one minute and 37 seconds before the backdraught occurred. This additional crew could have begun firefighting / venting duties prior to the re-committal of the Blaina BA crew who were caught in the backdraught. The second appliance could also have provided a BA emergency team.

--end--

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

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

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

IFE Commentary & lessons if applicable

None produced at this time.

Known available source documents

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

FRS Incident Report

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

FBU Incident Report/s

Pearson, D. & Allen, B. (circa 1996). Fatal Accident Investigation, 14 Zephaniah Way, Blaina, Gwent, 1st February 1996: Report and Conclusions. [pdf]. Fire Brigades Union (FBU).

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

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

Gwent Police Service Incident Report/s

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Welsh Ambulance Service Incident Report

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Building Research Establishment (BRE) Reports/investigations/research

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Coroner’s report/s and/or regulation 28 notices

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Other information sources

Grimwood, P. (1998). Compartment Firefighting – Strategy and Tactics. In: Institution of Fire Engineers (IFE) conference paper, Limerick.

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Service learning material

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