Incident directory

2016 - Orton Mere

16/01/2016

Country:

UK

  • Water Related Incidents

Severity:

Near miss

Description

Date of event

16th January 2016

Time of event

Approximately 10:30 (INITIAL CALL)

Name of premises

Orton Mere.

Location

Weir and Sluice Gates on The River Nene, near Orton Mere, Peterborough.

Service area

Cambridgeshire Fire and Rescue Service (CFRS).

Nature of incident

Water rescue training.

Property type

Automatic sluice gate on swift water river.

Premises use

Weir and sluice gate used automatically by the Environment Agency to control water levels on The River Nene, Peterborough.

Construction type and materials

Steel and concrete creating a system of sluice gates.

Occupancy

None.

Fire source and location of fire

N/A.

Synopsis

Brief Synopsis

Cambridgeshire Fire and Rescue Service attended the weir and sluice gate system on The River Nene near Orton Mere, Peterborough for a swift water rescue training session at approximately 09:26 on the 16th January 2016. The task set was to retrieve a ‘casualty’ from the sluice, familiarise with boat handling and related rescue equipment. A ‘casualty’ had been placed ‘next to a buttress between a gravity sluice and a sluice gate’. The inflatable rescue boat with a crew of 3 on board then proceeded to rescue the ‘casualty’. This manoeuvre required the boat to be under power so the bow was facing into the flow of the water and when the ‘casualty’ was retrieved the engine would be placed into astern and the boat would effectively reverse out of the scene/flow of water (CFRS, 2016).

During this course of action there was a sudden change in hydrology due to a sluice gate opening automatically, where by the boat began to lose buoyancy. Due to this, one of the crew members moved position resulting in the engine kill cord becoming activated. This caused the boat to lose power where it pivoted around so that the starboard side faced the flow of water. The boat began to fill with water and the 3 crew members were ejected from the boat. During this one crew member became trapped next to the weir and suffered a dislocated shoulder (CFRS, 2016).

The 3 crew members required rescue by the other firefighters on scene. One was conveyed to hospital by ambulance (CFRS, 2016).

lead photo

Courtesy of Cambridgeshire Fire and Rescue Service.

Photo 2

Screen shot of sluice gate activity for 16th January 2016, courtesy of Cambridgeshire Fire and Rescue Service.

Photo 3

Example of Environment Agency strong stream advice signs.

Main findings, key lessons & areas for learning

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

Cambridgeshire Fire & Rescue Service summary of main root causes and findings

Taken from Cambridgeshire Fire and Rescue Service (CFRS). (2016). Orton Mere training accident report.

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17.1  Immediate

(a) There was a change in the water conditions causing the boat to become unstable.

(b) As the boat became unstable the kill cord became detached from the engine causing the engine to stop.

(c) The boat pivoted round so the starboard side was facing the flow of water and began to fill with water. 

(d) This caused xxxxxx to be ejected from the boat followed by xxxxxx and then xxxxxx.

17.2  Underlying

(a) The risk assessment for the training site was unsuitable and insufficient.

(b) The risk assessment for the training session was unsuitable and insufficient.

(c) The safety brief for the training session was unsuitable and inadequate.

(d) There was insufficient clarity and understanding of who had command and control of the training session.

(e) There were two active training sessions taking place and a third planned, this added to the lack of clarity around command and control.

(f) Staff did not understand the hazards associated with the training venue in sufficient detail to complete a suitable and sufficient risk assessment.

(g) There were insufficient safety officers in place. A safety officer watching the water conditions next to the sluice gate may have been able to inform staff using the boat that the water conditions had changed.

(h) Staff did not fully understand the hazards the site presented.

(i) Staff were not aware that the sluice gate can operate automatically.

(j) CFRS and subsequently staff at the training venue were not aware of the strong stream advice warning in place at the time of the incident.

(k) Not all staff that are expected to complete risk assessments are suitably qualified.

17.3  Root Cause

(a) CFRS boat policy gives very limited information or direction on the use of boats. It does not give information on the use of boats near to weirs, sluice gates, locks or fast moving water.

(b) The existing guidance and policy on risk assessment is confusing and lacks clarity. The process of searching for instructions and information to complete risk assessments is complicated, time consuming and frustrating.

(c) There is a lack of information regarding locks, weirs, sluices and boat operation in fast moving water on the IPDS system. This makes it hard for staff to access relevant information. 

(d) There is complacency with staff when it comes to assessing the risk with regard to training. There is a lack of understanding from staff regarding the importance of assessing risk with regard to training.

The risk was not controlled for a number of reasons, listed below.

(a) Insufficient consideration had been given to a suitable and sufficient risk assessment for the training activities being completed:

When asked why there was no risk assessment for the training session xxxxxx replied “There was a site risk assessment any way. Not written down for the particular day as picked out the necessary parts of the existing one. It is not done for other training sites so why do it here.” (xxxxxx / xxxxxx interview 09/03/16 page 2 line 1). When asked what training xxxxxx has had on how to write a risk assessment and the methodology behind them xxxxxx said “Only when in North Wales on instructors course nothing else” (xxxxxx / xxxxxx interview 09/03/16 page 2 line 6). When asked if there was a written risk assessment for that day xxxxxx replied “Nothing written, discussed in the lecture room.” (xxxxxx / xxxxxx interview 09/03/16 page 2 line 9).

(b) No safety officers were in place, a safety officer positioned on the bridge may have been able to advice staff on the water conditions by the sluice gate/weir:

xxxxxx asked xxxxxx if safety officers were in place, xxxxxx was not sure and says there were people watching but xxxxxx wasn’t sure who the observers were (xxxxxx / xxxxxx interview 23/01/16 page 4 line 7). xxxxxx says “3 people were observing but not with a designated safety task” (xxxxxx / xxxxxx interview 23/01/16 page 2 line 11). xxxxxx said “I was one as the instructor, xxxxxx and xxxxxx were not specifically asked but were on the bank where training was being carried out, both trained and had access to equipment” (xxxxxx / xxxxxx interview 09/03/16 page 1 line 5).   

(c) There was risk information known on station that was not shared between staff:

One watch was aware that the sluice gates operated automatically, this watch would inform the water board that they were training at Orton Mere and ask that the gates are not operated. The watch were not aware the sluice gate may operate automatically. (xxxxxx interview 23/01/16, page 5 line 11)

(d) The processes detailed in GC SOP 2.4.1 Water Related Incidents (Appendix 2) has not been followed, which carries guidance for operational crews to ensure a ‘Safe System of Work’ for water training:

‘Pre-planning – to ensure personnel can be trained appropriately and resources are allocated according to the risks presented, a crucial element of this SSoW will be the gathering of risk information. Station Managers must ensure that crews identify significant water risk areas on their station ground and make provision for operational pre-plans as detailed below;

  • Where sites on non Level 4 RV stations are deemed to pose a significant risk, the local station must forward details to the nearest water rescue (RV) station; details must include a risk category of the site, ranging from high to very high. The RV station will then visit, confirm the risk and pre plan where necessary. Should a pre-planned system of work requires a specific action from “Level 1, 2 or 3 qualified” personnel, the local RV station must ensure that the relevant persons are fully briefed and informed of this. RV stations should record this data in the water risk folder.
  • Due to the potential workload involved in this process RV stations must prioritise this work, starting with the very high risk sites first.

Where sites warrant a risk visit from RV crews they must record the following details using form HSM 10: 

  • Site name, location, best access routes and water entry points;
  • Likely incidents and recommended SSoW for dealing with these incidents;
  • Additional hazards such as water quality etc.

Re-inspections should be arranged to ensure currency of information. Details must be kept in the RV water risk folder. Copies of HSM 10’s should also be forwarded to the Health and Safety Team.’

The essence of the above passage is that risk information should be gathered for all significant water risk areas on every station ground and provide operational pre-plans.

The first bullet point however details how this should happen for stations that are not level four (‘Level 4 - Water Rescue Boat Operator RV Station Capability - All parts of level 1 + 2 + 3 + Power boat rescue operations RV Stations’) qualified. For ease of comparison this would be all on call stations, and any others that do not have an RV. The guidance asks for these stations to ‘forward details to the nearest water rescue (RV) station; details must include a risk category of the site, ranging from high to very high.’ This would mean non-qualified personnel would be performing a risk analysis without the appropriate training and no guidance and ultimately create the possibility of a significant risk site being missed.

The rest of the guidance states RV crews should complete this process with the HSM10 process and documentation which carries its own significant areas identified for improvement.

(e)  The briefing on the day did not cover all the risks of the training site in sufficient detail:

The instructor cannot recall any specific safety points regarding the site being spoken about (xxxxxx / xxxxxx interview 23/01/16, page 2 line 4). The risk assessment for the site was not read out “word for word” on this drill session. It is generally accepted that risk assessments are not read out word for word. (xxxxxx / xxxxxx interview 23/01/16, page 5 line 20 and page 6). xxxxxx says there was a safety brief on station, however it was a general chat and xxxxxx can not recall the detail. There was a safety brief at the training venue, but xxxxxx was dealing with a kit issue. When the kit issue had been sorted the boat was in the water. xxxxxx assumes there was a safety brief but not involved. (xxxxxx / xxxxxx interview 23/01/16, page 1 line 3).

Staff were not aware the sluice gates may open automatically. xxxxxx said “Nothing in risk assessment says sluice gate may open remotely” (xxxxxx / xxxxxx 23/01/16 page 5 line 11) and also that “though it was push button to operate. Otherwise would not have put people in there” (xxxxxx / xxxxxx interview 09/03/16 page 2 line 17) xxxxxx said “it did not really occur to xxxxxx (xxxxxx / xxxxxx interview 09/03/16 page 1 line 20). xxxxxx said “seen the signs but had not really reacted to it” (xxxxxx / xxxxxx interview 09/03/16 page 1 line 12) xxxxxx said “did not understand venue, current sluice gate automatic operation and capability of boat in fast water. (xxxxxx / xxxxxx interview 10/03/16 page 1 line 18).

xxxxxx states the safety brief covered PPE and training objectives, xxxxxx says other matters may have been raised but xxxxxx can’t be sure. (xxxxxx / xxxxxx interview 23/01/16, page 2 line 6).

xxxxxx states that A16 did complete their own safety brief, this covered PPE within 3 meters of the water, accidental immersion procedure, helmets off (xxxxxx / xxxxxx interview 23/01/16 page 1 line 14). xxxxxx was not sure if all the fire-fighters would be aware of the risk assessment for the site, but the instructor and JO certainly would be. The risk assessment was not read out as it was a common training venue (xxxxxx / xxxxxx interview 23/01/16 page 2 line 14).

xxxxxx had a safety brief on arrival from xxxxxx, this covered up stream and down stream safety, hasty brief, basic information mainly.

xxxxxx was not sure if xxxxxx had completed a safety brief as xxxxxx was in the car park getting PPE ready (xxxxxx / xxxxxx interview 25/01/16, page 1 line 8).

xxxxxx did receive a safety brief from xxxxxx when they got to the site, this covered 3 meters from the water, in water, dry suit and fast flowing water. xxxxxx received a safety brief from xxxxxx for the throwing part of the session, xxxxxx can not recall the detail of the brief (xxxxxx / xxxxxx interview 25/01/16 page 2 line 5).

xxxxxx was asked if there was a safety brief on station, xxxxxx replied xxxxxx was not present for this as xxxxxx was working in the office. When at the site xxxxxx was giving a safety brief as xxxxxx was inflating the boat. The brief covered training objectives throw lines and tethered swimmers. xxxxxx was not aware of any specific safety provisions for the whole site. xxxxxx was not aware of any specific risk assessments being referred to at any point as xxxxxx wasn’t present at the station brief and left the training site early to attend A18 (xxxxxx / xxxxxx interview 01/02/16 page 1 & 2).  

xxxxxx had a safety brief on station, this covered general things. xxxxxx gave a second brief on site, xxxxxx can not really recall what was said. xxxxxx has not viewed a risk assessment for the site for a while. When asked what site specific measures were put in place for the site xxxxxx said it was to ensure correct PPE was being worn.

(f)   There was a lack of clarity as to who had overall command and control of the training session:

xxxxxx said that “Normally xxxxxx but in xxxxxx absence xxxxxx” (xxxxxx / xxxxxx interview 09/03/16 page 4 last question).

xxxxxx said “xxxxxx recognised as being in charge” (xxxxxx / xxxxxx interview 09/03/16 page 2 line 13).

xxxxxx said “As understood it training was under xxxxxx responsibility” (xxxxxx / xxxxxx interview 10/03/16 page 2).

xxxxxx when asked if there was a formal handover to xxxxxx said “Not specifically, although hand over was to xxxxxx” (xxxxxx / xxxxxx interview 09/03/16 page 1 line 3).  

(g) There was not a suitable procedure or plan in place to deal with a situation should something go wrong:

xxxxxx explained the plan as “had a boat that could act as a safety boat, rescue swimmer available and rescue sled available for deployment if required” (xxxxxx / xxxxxx interview 09/03/16 page 2 line 10).

xxxxxx said when asked if there was a procedure in place for something going wrong “only one boat used, sled inflated plus all water equipment out. Other than that no.” (xxxxxx / xxxxxx interview 09/03/16 page 1 line 4).

(h) Not all staff were at the safety briefs:

xxxxxx was not aware of any site specific safety procedures being in place as xxxxxx was dealing with kit issues at the time of the brief (xxxxxx / xxxxxx interview 23/01 16, page 3 line 13). 

xxxxxx was not aware of any specific risk assessments being referred to at any point as xxxxxx wasn’t present at the station brief and left the training site early to attend A18 (xxxxxx / xxxxxx interview 01/02/16 page 1 & 2). 

xxxxxx said when asked if xxxxxx had given a safety brief “not sure as getting PPE ready at appliance A14 which was at the car park” (xxxxxx / xxxxxx interview 25/01/16 page 1 line 12). 

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

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

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

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

IFE Commentary & lessons if applicable

None produced at this time.

Known available source documents

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

FRS Incident Report/s

Cambridgeshire Fire and Rescue Service (CFRS). (2016). Orton Mere training accident report. [Accessed 15th November 2016].

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

FBU Incident Report/s

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

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

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

Cambridgeshire Constabulary Incident Report/s

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

East of England Ambulance Service Incident Report

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

Building Research Establishment (BRE) Reports/investigations/research

Not relevant

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

Not relevant

Other information sources

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

Service learning material

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

Videos available

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

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