Incident directory

2013 - Paul's Hair and Beauty World, Oldham Street



  • Building Fires




Date of event; 

13th July 2013                 

Time of event;


Name of premises;

Pauls Hair and Beauty World


Oldham Street, Manchester.

Service area; 

Greater Manchester Fire and Rescue Service (GMFRS).

Nature of incident;


Property type;

Ground floor shop (Paul’s Hair and Beauty World) approximately 16 m x 33 m with 3 floors above, a basement and adjoining shop also on ground floor. Total premises size approximately 30 m at front, 20 m at rear and 43 m in length.

Premises use;

Shop selling hair and beauty products with 3 floors above with a variety of uses and a basement used as a nightclub. Ground floor also had a separate cloths shop present.

Construction type and materials;

Steel frame, brick & block walls with concrete floor under a 2 part flat and part pitched slate roof. Building was approximately 100 years old.


Customers and staff.

Fire source and location of fire;

Deliberate ignition involving application of flaming items to waste materials behind a door.


Brief Synopsis;

Greater Manchester Fire and Rescue Service (GMFRS) were called to a fire at Pauls Hair and Beauty World, Oldham Street, Manchester on the 13th July 2013 at approximately 14:49. The fire started at the rear doors to the shop on the ground floor of the premises and had been discovered at approximately 14:44. 3 pumping appliances were initially mobilised to the fire, the first attending appliance arriving at approximately 14:55 and was directed to the rear of the premises from the front of the premises at Oldham Street. While appliances were en route, the incident was upgraded to persons reported due to the fact the manager of the shop was believed to be missing. At approximately 14:56 a second appliance arrived at the front of the premises shortly followed by the third at approximately 15:00. Initially 2 breathing apparatus (BA) wearers were committed, at approximately 14:58, via the rear door (doorway A on plans), with a high pressure hose reel jet (HPHRJ) to make an initial attack and gather information on the fire. Conditions inside were initially described as ‘very hot with very thick smoke reducing visibility to almost zero’ (WYFRS, 2014).

The incident had initially been sectorised into sectors 1 (Tib Street at rear of premises) and sector 3 (Oldham Street at front of premises).

The stock and contents of the shop provided a significant fuel loading which included real and synthetic hair extensions, aerosols, peroxides, hair dyes and acetones. Large amounts of smoke was produced. It was estimated that water was put onto the fire at 14:58 at the rear, approximately 14 minutes after discovery of the fire by staff. At approximately 15:00 a second BA team was committed via the front (doorway B on plans), also with a HPHRJ, to search for the missing manager. Conditions within, via the front, were described as ‘not hot’ but with ‘very thick black smoke from floor to ceiling’ (WYFRS, 2014). The manager was located outside of the premises and the fire was no longer confirmed as ‘persons reported’ however due to the possibility of customers still being within the incident remained ‘persons reported’. Firefighters (Ff) were withdrawn from the premises at the front (by now sector 3) due to deteriorating conditions and firefighting continued here externally with the main seat of operations via the rear, now sector 1 (GMFRS, 2013).

At 15:02 a make pumps 4 assistance message was sent. At 15:14 a make pumps 6 assistance message was sent from the Group Manager (GM) who had assumed command. An aerial appliance, an enhanced rescue unit and supporting officers were also sent a short time afterwards. At 15:29 a make pumps 12 assistance message was sent with an additional 6 pumps and a command unit sent. At approximately make pumps 12 an additional sector (sector 4) was added. Further supporting officers were also sent, up to Area Manager (AM) role. An Assistant Chief Fire Officer (ACFO) also attended at approximately 16:30 however he had not been not directly mobilised to the incident.

At 18:38 an 8 pump relief was requested for 19:00 due to the change of day to night shift. At approximately 18:58 tactical ventilation which included the smashing of windows within Sector 3 was carried out. BA teams had been withdrawn to allow an assessment of this tactic (GMFRS, 2013). When BA crews were recommitted a short time later it was observed that the smoke conditions had improved, however the fire had ‘developed significantly causing a deterioration in conditions’ (WYRFS, 2014). An additional aerial appliance was requested at 19:14.

During incident time described so far, the fire had developed and multiple BA wearers had been committed to attack the fire with some being recommitted multiple times. The fire was deep seated and had been difficult to locate and attack due to the hot, very smoky conditions and large quantity of stock making access difficult. Several external jets had also been directed into the premises. BA teams had been withdrawn on several occasions when conditions deteriorated, until conditions had improved, when internal firefighting continued.

At approximately 20:04 the BA team that was injured including Ff Hunt, were committed with a 45mm jet and a thermal imaging camera (TIC) to fight the fire via the rear (doorway A). Conditions were described as much hotter than the 50oC maximum that the TIC had registered. The BA team were said to be beginning to ‘feel the heat’ (Gibbins, 2016) and became disorientated and lost. They decided to request assistance via their radio communications but they failed to make contact with BA control. The BA team tried to retrace the path of the hose but after a short distance discovered it was covered with collapsed stock. Another BA team sent to relive Ff Hunt and his BA partner were committed at approximately 20:26. This team located the disoriented BA team and the branch was given over to the fresh BA team. The now heat stressed, disoriented BA team (Ff Hunt and his BA partner) attempted to leave the premises but failed to find the exit door and both BA wearers became separated. Another BA team located one BA wearer in a distressed condition and rescued him at approximately 20:35 (GMFRS, 2013 & Gibbins, 2016).

At 20:35 a BA Emergency was declared. Ff Hunt was found at approximately the same time and was removed from the premises at approximately 20:41 where he received treatment from trauma care trained firefighters and the North West Ambulance Service. Ff Hunt died from his injuries (GMFRS, 2013).

Photo 1

Courtesy of Greater Manchester Fire and Rescue Service.

Photo 2

Staircase C area looking towards staircase A area. Courtesy of Courtesy of Greater Manchester Fire (WYFRS, 2014).

 Photo 3

 Courtesy of Greater Manchester Fire and Rescue Service (GMFRS, 2013).

Photo 4

Courtesy of Greater Manchester Fire and Rescue Service (GMFRS, 2013).

Photo 5

Courtesy of Courtesy of Greater Manchester Fire and Rescue Service (GMFRS, 2013) & West Yorkshire Fire and Rescue Service.

Photo 6

Courtesy of Courtesy of Greater Manchester Fire and Rescue Service (GMFRS, 2013).

Photo 7

Courtesy of Courtesy of Greater Manchester Fire and Rescue Service (WYFRS, 2014).

Photo 8

Origin of the fire. Courtesy of West Yorkshire Fire and Rescue Service (WYFRS, 2014).

Photo 9

Courtesy of Greater Manchester Fire and Rescue Service (WYRFS, 2014).

Photo 10

Firefighters entering doorway A. Unknown time of incident. Courtesy of Greater Manchester Fire and Rescue Service (GMFRS, 2013).

Photo 11

Firefighters on staircase A inside doorway A. Unknown time of incident. Courtesy of Greater Manchester Fire and Rescue Service (GMFRS, 2013).

Photo 12

View from top of staircase A looking towards staircase C. Understood to be post incident. Courtesy of Greater Manchester Fire and Rescue Service.

Photo 13

Fire at front at approximately 14:58. Courtesy of Greater Manchester Fire and Rescue Service.

Photo 14

Courtesy of Greater Manchester Fire and Rescue Service.

Photo 15

Stock within stair area near doorway A. Courtesy of Courtesy of Greater Manchester Fire and Rescue Service (WYFRS, 2014).

Photo 16

Staircase C area looking towards staircase A area. Courtesy of Courtesy of Greater Manchester Fire (WYFRS, 2014).

Main findings, key lessons & areas for learning;

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

Taken from (Greater Manchester Fire and Rescue Service, 2013).


Part 2: Post Incident

Section 1: Immediate Actions

2.1.1 Following the events that unfolded on the night of July 13, Greater Manchester Police (GMP) and The Health and Safety Executive (HSE) conducted investigations to establish the facts surrounding the incident. GMFRS brought together a dedicated team to support GMP and the HSE in expediting their investigations.

2.1.2 It was determined that this team would remain in place until the completion of the coronial process (concluded May, 2016), the findings of which have been summarised within this report.

2.1.3 GMFRS contacted the Health and Safety Executive on the night of the incident to inform them of the events that had taken place and the Chief Fire Officer (CFO) informed the Fire Brigades Union (FBU).

2.1.4 Following the events at the incident, all crews and officers at the scene were relieved at the earliest opportunity, in recognition of their welfare needs. They were brought to the GMFRS Training and Development Centre to allow for some immediate defusing activity. The crews were then asked to take some time and provide their initial accounts, whilst their memories were fresh to help with any subsequent investigations.

2.1.5 An Area Manager was appointed as a GMFRS Family Support Officer and maintained relations with the family and GMP’s Family Liaison Officers through to the Coroners hearing in May 2016 and beyond.

2.1.6 GMP appointed a Major Investigation Team to work with investigators from the HSE and they were further supported by:

  • Merseyside Fire and Rescue Service providing an investigation into the origin, cause, and the subsequent development of the fire.
  • West Yorkshire Fire and Rescue Service who provided technical guidance of Fire and Rescue Service practice and procedure to GMP and the HSE.
  • A former Deputy Chief Fire Officer was appointed by the Coroner to provide independent expert advice to the Inquest.

2.1.7 GMP conducted witness interviews with 136 GMFRS employees involved in the incident and produced 57 witness statements.

Section 2: HSL Investigations

2.2.1 The Health and Safety Laboratory (HSL) summarised their report into five distinct areas of testing; Breathing Apparatus (BA) and Personal Protective Equipment (PPE), BA Alarm Systems, Scott Eagle Attack Thermal Imaging Camera, Entel Fireground Radio and Thermal Environmental Effects on Firefighters.

2.2.2 BA and PPE: All BA and PPE examined were designed for structural firefighting and during testing there was no indication of significant failure or malfunction occurring during the incident. There was evidence of several shortcomings in maintenance procedures associated with the use of BA, however HSL are of the opinion that these shortcomings had no bearing or impact on the events at the incident. Specific to BA, HSL made eight recommendations, all of which were centred on review of maintenance procedure. The current maintenance procedures within GMFRS are suitable and sufficient to address the recommendations.

2.2.3  BA Alarm Systems: Following testing of both the pneumatic and electronic low pressure alarms HSL concluded that, as these alarms activate simultaneously, there is no question that audibility of these alarms would have been an issue during the incident. As a result, no recommendations were levied within this section of the HSL report. They did note however that when tested in isolation the pneumatic whistle on FF Hunt’s BA Partner’s BA set and the electronic low pressure alarm on FF Hunt’s BA set were borderline pass and marginal fail respectively.

2.2.4 Thermal Imaging Camera: Following testing of all Scott Eagle Attack thermal imaging cameras used by GMFRS, HSL concluded that all cameras worked as intended. They went on to point out that these cameras are intended to be used to highlight areas of high temperature but are not designed to read the environmental surroundings (ambient temperature). Again there were no recommendations from this section of the HSL report.

2.2.5 Entel Fireground Radio: This part of the HSL report detailed the testing of both the fireground radio (attached to BA set) and the radio utilised by the Entry Control Officer (ECO). During all functional tests both radios performed within design and operational parameters. HSL did however identify potential issues with battery life and charging procedures leading to two recommendations. These two recommendations were around reviewing procedures associated with battery charging and discharge cycles. As GMFRS no longer use Entel fireground radios, these recommendations are no longer applicable. However the manufacturer has been made aware of these findings.

2.2.6 Thermal Environmental Effects on Firefighters: For this part of the HSL report the Executive were asked by West Yorkshire Fire and Rescue Service (WYFRS) to complete a literature review into the subject of firefighter physiology within compartment fires. HSL suggest that current knowledge into this field indicates that human tolerance time when working in full PPE and working in routine firefighting environments would not exceed 20 minutes. They did however go on to state that   as variables combining to produce a physiological effect cannot be determined specific to the Oldham Street incident, it is impossible to conclude, in terms of a specific time, when the onset of detrimental physiological effects occurred. Although they did go on to hypothesise that it would be reasonable to assume that both firefighters would have been severely affected by conditions, possibly to the extent that their physical and mental capacity to escape was compromised. It is clear from the HSL report that there are many contributory factors which affect a firefighter’s physiological response within a compartment fire situation. It is these factors and variables that, through the commissioning of research, GMFRS wish to develop dynamic and more pragmatic control measures to help determine more accurately, deployment time scales against firefighters physiological tolerances. (See Section 4 for more details).

Section 3: Fire Investigation

2.3.1 To demonstrate impartiality Merseyside Fire and Rescue Service (MFRS) Incident Investigation Team (IIT) was requested by GMFRS to independently carry out the investigation in to the origin, cause and development of the Paul’s Hair & Beauty World Fire.

2.3.2 A multi-agency investigation team spent a number of weeks excavating and examining the scene. At the conclusion of the investigation the IIT were satisfied that the fire had originated in the cardboard recycling area adjacent to the rear exit doors facing Tib Street (doorway ‘A’).

2.3.3 The team considered both accidental and deliberate as possible causes of the fire and concluded, after considering all the physical evidence, the timeline and the information ascertained from witnesses, CCTV and other persons at the scene that most likely cause was the application of a naked flame.

2.3.4 This evidence was collated by GMP and passed to the Crown Prosecution Service (CPS) for consideration; however in April 2015 it was decided by the CPS that no further action would be taken against any individual(s).

2.3.5 Following the conclusion of the Inquest in 2016, evidence that was presented in  Court was passed on to the CPS in order to again establish whether there would be any further legal action taken against the individual(s) accused of starting the fire. After an examination of this evidence the CPS concluded;

  • There was no new and compelling evidence arising from the Inquest which was not available to the Prosecution when earlier decisions were taken in this case;
  • There is no viable legal mechanism for the further prosecution;
  • There is no reason, emerging from the evidence at the Inquest, to revisit the decisions taken by the Prosecution as to charge and/or disposal of the criminal investigation.

Section 4: Coronial Inquest

2.4.1 A Coroner was appointed to oversee the Inquest into the death of FF Hunt which commenced on April 4, 2016 and concluded on May 18, 2016. The evidence was presented and witnesses were called under three main areas:

  • Start of the fire / fire investigation
  • Fire risk management
  • Firefighting operations

The start of the fire has been discussed in Section 2.3 and below is a summary of the jury responses to the fire risk management and firefighting operations related questions posed by the Coroner at the end of the process.

2.4.2 Questions relating to fire risk management, the jury found that;

  • The presence of the cardboard storage area and the racking up the stairs contributed to the fire developing.

2.4.3 Questions relating to firefighting operations, the jury found that;

  • In relation to the control measures that were in place during the afternoon

» BA crews were limited during the day shift and that time was a maximum 20 minutes.

» Most BA crews were probably told to remain at the top of the stairs and fight the fire from there only.

» Other control measures included a second Safety Officer to keep an eye on the BA crews.

»   The safety control measures identified above were not communicated to the Entry Control Officer who sent Stephen and his partner into the building nor were they communicated to the Entry Control Officer at the change of shift.

» The above control measures were however communicated to the new Sector Commander for Sector One at the changeover of shifts.

  • The jury found that safety measures were in place when Stephen and his colleague entered the building, but not implemented. These measures should have been carried through over handovers.
  • The jury also found that the new Sector Commander misinterpreted the brief and the new Entry Control Officer was not fully informed, and therefore could not implement safety measures.
  • At the time Stephen and his colleague entered the building a number of officers at the incident were aware that the previous BA teams had been limited to a 20 minute wear.
  • Various officers also knew that teams were being directed to go to the top of the stairs and fight the fire at that point but go no further and that a safety officer had been dedicated to watch over them and keep in communication.
  • The jury concluded that Stephen and his colleague were given two briefs, initially from the Entry Control Officer “to go to the top of the stairs, take over, sit there and squirt water - top of the mezzanine, you know what the crack is”.
  • The 2nd Safety Officer gave “go to the top of the stairs, turn left, look right, and use the thermal imaging camera and spray water from there”. This second brief removed the word ‘mezzanine’ and contained no direct instructions.
  • The jury also concluded that Stephen and his colleague had followed their brief as they understood it. They stated that confusion, due to the use of the term ‘mezzanine’ and ‘seek out hotspots’ may have led to misunderstanding of the brief.
  • Finally, the jury were asked what factors probably contributed significantly to

»      Lack of communications and information at handovers
»      Lack of communications and information at briefings and debriefings
»      Misinterpretation of instructions
»      Incorrect decision-making
»      Competency within the roles given
»      Paul’s Hair World storeroom layout, internal conditions, stock debris and smoke detection
»      Breakdown of telemetry and radio communications
»     Inadequate fire risk assessment
»     Inadequate fire safety measures in Paul’s Hair World e.g. fire drills

Part 3: Conclusions

3.1.1 As a result of the GMP and Coronial investigations a number of conclusions were reached by the jury. Part 4: Recommendations, details the lessons learnt by GMFRS and the recommendations of the Coroner, the following section is a response to the narrative conclusions of the Jury and also includes the findings of the GMFRS internal investigation.

3.1.2 Jury Point 1; The control measures from the afternoon, 20 minutes of wearing BA, being told to remain at the top of the stairs and to fight the fire from there only and the use of a 2nd Safety Officer were communicated to the Night Shift Sector One Sector Commander at the changeover of shift. However they were not communicated to the Day Shift Entry Control Officer Sector One or the Night Shift Entry Control Officer Sector One as ECO’s. The jury stated that the Sector Commander misinterpreted the brief.

3.1.3 Established facts;

  • The Day Shift Sector One Sector Commander wanted the 2nd Safety Officer Sector One to act as a 2nd Safety Officer with the specific task of closely monitoring BA crews in Sector One and maintaining communication. The 2nd Safety Officer Sector One had been in place for the duration of the day shift. This role was not replaced at the change of shift.
  • The Night Shift Sector Four Sector Commander was briefed by the 2nd Safety Officer Sector One on the role of 2nd Safety Officer, however the Night Shift Sector Four Sector Commander was directed to another role (Sector Four Commander) by the Operational Support Officer (OSO) and a replacement was not established.
  • The control measure employed during the day relating to the limited duration of BA wears at doorway ‘A’, although used flexibly by the 2nd Safety Officer Sector One (depending on conditions) was not recorded contributing to a lack of continuity into the night  shift.
  • The limit on the time the BA wearers were committed was also not translated into cylinder contents as per Technical Bulletin 1/97.
  • Handover procedures varied from sector to sector. Sector Three replaced all staff directly, like for like. The Day Shift Sector One Safety Officer, left before his replacement, the Night Shift Sector One Safety Officer arrived. The 2nd Safety Officer Sector One’s role was not recorded. The Night Shift Sector One Commander removed his tabard for a period of time leaving the sector unsupervised for approx. 9 minutes.

3.1.4 GMFRS Conclusion; There was no assurance process to ensure the above failures were avoided. The command team, led by the Incident Commander who, as stated earlier, was being mentored by the Area Manager, did not instigate a process that ensured that functional roles and the control measures that had been in place at sector level were maintained, carried forward or removed with  justification.

3.1.5 When handing over the command of sectors the Incident Command Manual specifies that a clear and precise exchange of information must be undertaken. This also places a responsibility on the individuals carrying out those roles.

3.1.6 Jury Point 2; When FF Hunt and his BA Partner entered the building a number of officers were aware of the 20 minute limit, only fighting the fire from the top of the stairs and the dedicated 2nd Safety Officer.

3.1.7 Established facts;

  • During the analytical risk assessment process various hazards and control measures were recorded, however the ones relating to these control measures were not logged.
  • The Night Shift Sector One Sector Commander was aware of the 20 minute limit but did not inform the Night Shift Entry Control Officer Sector One. The Entry Control Officer had not been made aware of this, so used the existing time of whistle calculation, the Day Shift Entry Control Officer Sector One had established of 20:32, this equated to a 33 minute BA wear.
  • The Pump Operator raised concerns; with both the Night Shift Entry Control Officer Sector One and the Night Shift Sector One Sector Commander about the lack of communications and that the team were not delivering water. Despite the Night Shift Sector One Sector Commander being aware of the 20 minute limit and the Night Shift Entry Control Officer Sector One being aware of the lack of communication, these concerns were not acted upon.

3.1.8 GMFRS Conclusion; there was no assurance process to ensure the above failures were avoided and that the control measure of 20 minutes was maintained.

3.1.9 There were individuals at sector command level, the Night Shift Sector One Sector Commander and the Night Shift Entry Control Officer Sector One, who did not maintain a safe system of work prior to, and whilst this situation was  developing.

3.1.10 Jury Point 3; FF Hunt and his BA Partner were given two briefs, the Day Shift ECO told them to go to the top of the mezzanine, however the 2nd Safety Officer removed the word ‘mezzanine’, and mentioned seeking out hotspots. This confusion may have led to a misunderstanding of the brief.

3.1.11 Established facts;

  • FF Hunt’s BA Partner states that FF Hunt and he believed that they had reached the mezzanine when they had got to the top of staircase ‘A’.
  • FF Hunt’s BA Partner understood they were to go to a point in the building and search for hotspots with the TIC. He went on to state that he understood from the brief that they were not to search the building.
  • The previous BA team, BA Team 3 FF ‘A’ and ‘B’, should have briefed and been de-briefed by the ECO when they exited the building. The Day Shift Entry Control Officer Sector One should also have ensured that this de-brief was carried out, ensuring relevant information, location, conditions etc. could have been passed on to FF Hunt and his BA Partner (the next team to wear in doorway ‘A’)

3.1.12 GMFRS Conclusion; although the briefs differed, the presence of the 2nd Safety Officer throughout the day helped to counter any potential misinterpretations that may have arisen. Therefore the previously discussed omissions that led to that role not being replaced, i.e. with no assurance process by the command team, this must be considered a contributory factor.

3.1.13 Failure to exchange critical information by the BA team and the ECO as per agreed procedures could also have contributed to the inconsistence in the briefs.

3.1.14 Although the jury identified that there were inconsistencies in the two briefs, particularly with the use of the word ‘mezzanine’, FF Hunt and his BA Partner believed they were on a mezzanine level when they had entered the building and ascended the first set of stairs. The inconsistencies also include the use of the phrase ‘search out hotspots’ which may have led to them to advance further into the building.

3.1.15 Jury Point 4: Other personnel factors that probably contributed to the death were;

»      Lack of communications and information at handovers
»      Lack of communications and information at briefings and debriefings
»      Misinterpretation of instructions
»      Incorrect decision-making
»      Competency within the roles given
»      Loss of communications
»      Handing over

3.1.16 Established facts;

  • There was a relief plan to assist the handover however this wasn’t adhered to in its entirety, leading to confusion as to who was doing what role at sector level in Sector One. The Welfare Officer had drawn BA wearers away from their appliances to supplement the BA pool as per Main Control procedures. Operationally, this was not compatible with the ‘like for like’ plan devised by the Operational Support Officer and the Logistics Officer, which would have kept all crews together.
  • The Day Shift Sector One Safety Officer left his sector without handing over to the Night Shift Sector One Safety Officer who had been designated to fulfil the role for the night shift. The Night Shift Sector One Safety Officer was allocated this role when he reported to the Command Unit crew, however he cannot recall exactly by whom.
  • The level of hazard and control measure recording (2nd Safety Officer, 20 minute duration etc.) was not consistent leading to gaps in continuity from the day shift to the night shift.
  • There were indicators and concerns raised at the incident that were not acted upon e.g. the Pump Operator highlighting the lack of water being delivered, the lack of communication from the BA team and the loss of telemetry. There was no appropriate response from the functional officers, the Night Shift Entry Control Officer and the Night Shift Sector One Sector Commander, who were supervising the BA deployment in Sector One.
  • FF Hunt’s BA Partner’s BA set lost telemetry early into his wear, at 20:07. A green flashing light would have indicated this loss on the BA board. The ECO states he was not aware that telemetry had been lost, however at 20:24 FF Hunt’s BA Partner’s tally was removed from the board and re-inserted. This coincided with the ECO committing the next BA team through the same BA board. The ECO does not recall removing and re-inserting the tallies.
  • The Night Shift Sector Three Sector Commander did not inform anyone within the command structure when he moved the aerial monitor from the first floor to the ground floor. However, the Technical Advisor to the Coroner stated during the Inquest that he “would not expect a significant impact at the rear of the building” with this action.
  • The Night Shift Sector Three Sector Commander stated that if he had known firefighters were committed at the rear he would not have used the aerial appliance to deliver water. During the Inquest the Coroner concluded that different tasks carried out within the same building (e.g. application of water and BA wears) should be communicated.
  • CCTV footage shows at least one BA team stood by the Sector One entry control board from approx. 16:00 onwards. The Night Shift Entry Control Officer Sector One did not replace the emergency team after using them to relieve FF Hunt and his BA Partner at 20:26. There were no emergency teams in Sector One from this point onwards. When the BA emergency occurred at 20:34 there were 6 BA wearers already under air in close proximity to the Sector Four entry point, stairway ‘C’. These were the same 6 BA wearers that carried out the rescue of FF Hunt and his BA Partner. Extra BA teams arrived in the sector after the BA emergency was declared at 20:34.
  • CCTV footage shows that there was also no BA emergency team available in Sector Four following the change over to the night crew. This is confirmed by the Night Shift Sector Four Sector Commander, however, he stated that he had asked BA Main Control to send 4 BA to Sector Four, two BA to act as an emergency team; however, he only got two BA wearers, BA Team 7 FF ‘A’ and ‘B’. As the task was only to enter and reposition the ground monitor, he determined that he would allow them to proceed in prior to receiving another team.
  • An Area Manager (AM) was mobilised to assume the role of Incident Commander, he agreed not to take charge but remained at the incident, in a mentoring role, for the next five hours. The Area Manager was the most senior officer present.

3.1.17 GMFRS Conclusion; The decision of the Area Manager (AM) not to take charge but remain at the incident for the next five hours caused some ambiguity for the investigation when trying to absolutely determine the responsibility for critical operational decisions that needed to be identified. GMFRS policy at the time of the incident did allow senior officers the flexibility not to take charge of an incident, but to remain in a mentoring capacity. GMFRS has since revised its guidance, ensuring that the senior FRS officer present will be in command of the incident (further details in Part 4).

3.1.18 the relief plan across the incident wasn’t recorded, managed adequately or adhered to. This led to periods where supervision was not sufficient, for example, no safety officer for a period of time in Sector One, the Night Shift Sector One Safety Officer was not briefed by the Day Shift Sector One Safety Officer, and the 2nd Safety Officer Sector One was not replaced.

3.1.19 the level of hazard and control measure recording was not consistent, leading to gaps in continuity from the day shift to the night shift. Since this incident GMFRS has introduced a more formal handover form that serves as both a prompt and a formal record. However this investigation has highlighted the need for GMFRS to introduce a more robust process at all levels from the sector officers to the overall incident commanders. (Further details in Part 4).

3.1.20 there were indicators at the incident that should have raised concerns regarding the safety of FF Hunt and his BA Partner. The lack of communication, lack of water used by FF Hunt and his BA Partner and the loss of telemetry should have prompted an earlier response from the functional officers (the Night Shift Entry Control Officer and the Night Shift Sector One Sector Commander).

3.1.21 The Night Shift Entry Control Officer did not follow basic BA procedures by not replacing the emergency team as per BA procedures leaving a period of 8 minutes without this safety measure before the BA emergency began and extra BA teams began to arrive in the sector.

3.1.22 CCTV footage shows that 6 BA wearers were already under air and in the risk area, which, once the alarm was raised, resulted in an immediate response to carrying out the rescue of FF Hunt and his BA Partner.

3.1.23 GMFRS acknowledges the acts of heroism performed by those personnel carrying out the rescue of FF Hunt and his BA Partner. GMFRS and other public bodies view the actions of individual firefighters as heroic when they have put themselves at risk to protect the public or colleagues.

Part 4: Lessons

Section 4.1: Learning the lessons

4.1.1 Much time and effort has been invested into understanding this incident and to identify any learning opportunities that can be achieved organisationally, by Greater Manchester Fire & Rescue Service (GMFRS). The findings will be shared across FRS’s with the objective of minimising the chance of a similar tragedy occurring in the future. It is recognised that changes to policy and procedure must be communicated properly in order to entrench the learning until it becomes second nature.

4.1.2 GMFRS formed a dedicated team following this incident and they have carried out an ongoing analysis of events at Oldham St. Where development needs have been recognised, steps have been taken to work towards the resolution of the issues. Some of these proactive measures tie in with the Coroner’s Regulation 28 recommendations. These recommendations refer to the situation at the time of 13th July 2013 and thus, some of the issues described in the letter have already been part resolved. All work appertaining to the outcome of the Oldham Street investigation that has already been initiated or completed is provided in a table format and can be found in Appendix ‘C’.

4.1.3 The Fire Brigades Union (FBU) compiled a report for the Coroner, into the death of Stephen Hunt based on the analysis of recommendations from previous coroners inquests into Firefighter fatalities. This report was presented to the Coroner prior to his verdict. To ensure that lessons from previous Inquests have been learned by Fire and Rescue Authorities and Government, the FBU have made a series of recommendations within the report. GMFRS acknowledge the FBU recommendations and a response from them to the Coroner are provided at Appendix ‘D’.

4.1.4 A report was sent from the Coroner to the Home Secretary and the Chief Fire and Rescue (CFRA) Advisor under Regulation 28 and 29 of the Coroners (Investigations) Regulations, 2013. This report formally identified 10 ‘Matters of Concern’ raised as suggestions. GMFRS has established an internal ‘Task and Finish’ group to ensure that all of these concerns are addressed. Those actions are summarised in the table at Appendix ‘E’.

Section 4.2: GMFRS Response

4.2.1 Based on the findings of the jury, the Coroner, assisted by GMFRS and the Fire Brigades Union (FBU), made the following recommendations to prevent future Firefighter deaths. Those recommendations plus the GMFRS response are as follows;

4.2.2 Physiology; It is recommended that all FRSs should consider the implementation of measures to reduce the risks associated with the physiological effects of working in a hot environment. In particular consideration should be given to:

  • Duration of wears under breathing apparatus;
  • Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances.
  • Training and guidance for all operational personnel to recognize the effects of heat, both on themselves and on their colleagues, and the appropriate steps to take upon such recognition, including withdrawal and self-withdrawal.
  • Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
  • Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.

4.2.3 GMFRS response: At the time of this incident in July 2013, Home Office Technical Bulletin 1/97 set out the breathing apparatus (BA) procedures to be adopted by all Fire and Rescue Services (FRS)’s at operational incidents. Within this document there is very little reference to physiology and the effects of heat on firefighters. GMFRS had addressed this issue to some extent through internal practical training themes and guidance, but perhaps did not have an emphasis on this aspect of physiology whilst wearing BA at operational incidents. The importance of recognition of the effects of heat on the individual (whether on the BA wearer or a colleague) cannot be undervalued and must underpin all BA training moving forward.

4.2.4 The Technical Bulletin 1/97 has now been superseded by Department for Communities and Local Government (DCLG) Guidance Document: Operational Guidance Breathing Apparatus (OGBA), published in 2014. OGBA, Section B-8 ‘Welfare of BA Wearers’, references physiology considerations and, since its introduction, all GMFRS training materials have been updated to reflect this content. The review and introduction of the new breathing apparatus procedures in line with the national guidance was approved at the GMFRS Joint Health and Safety Committee in February 2015. In addition all GMFRS training and guidance notes applicable to Breathing Apparatus are currently being ordered into an overarching Breathing Apparatus policy and procedure document for publication in December 2016.

4.2.5 Work is programmed going forward to review training content, frequency and delivery in the area of physiology and BA. This will evaluate if GMFRS are giving the appropriate balance and emphasis to this area of development, and to address any shortcomings. Regular assessable ‘practical’ training will be carried out from a new bespoke training site in Bury from April 2017 to ensure understanding of this subject. The emergency actions to be taken where difficulties are encountered by the individual or colleagues whilst wearing BA, including withdrawal, activation of ADSU and calling of ‘BA Emergency’ will be incorporated in the training  content. Assessable ‘theoretical’ training to include key questions ensuring understanding of the effects of heat on the individual as well as other risk critical information is due to be introduced through a new online training tool by the end of  2016.

4.2.6 Following this incident it was recognised that there was insufficient operational guidance available, and the ‘Welfare of Personnel at Incidents’ service order was produced. Guidance around the duration of wears in relation to variable factors such as ambient temperature and condition of the wearer is found in this document. It provides information on the availability of refreshments and rest facilities as well as advising on core temperature, recovery and re- deployment. It details advisory rest and rehydration actions for BA wearers and other considerations appropriate to physiology and welfare of the individual.

4.2.7 In 2014, in conjunction with Salford University and Draegar, GMFRS initiated a research and development project into technology that can be utilised in the operational arena to monitor, in real time, a Firefighters physiology. This control measure will ultimately assist safety by giving an indication of the condition of the Firefighter when considering allocation of tasks and duration of wears. Trials will begin in late 2016 at Salford University to test this monitoring equipment. This will validate the protocols that will be used in this project.

4.2.8 Communications; It is recommended that all FRSs should consider the implementation of measures to reduce the risks associated with the loss of communications at operational incidents. For example, to include safety control measures to ensure BA teams can be withdrawn from the risk area if needed.

4.2.9 GMFRS response: Following the incident, questions were raised around both telemetry and radio communication between the BA wearers and the Entry Control Officer (ECO). There were also questions raised around the availability and location of emergency teams. This has led GMFRS to review its emergency procedures. At the time of the incident, GMFRS operated in line with Technical Bulletin 1/97 at Section CMP6C.

4.2.10 since then GMFRS has adopted DCLG Guidance Document: Operational Guidance Breathing Apparatus (OGBA), 2014. Communication is one of the key principles in this document, Section 5.9 states: “Good communications between the entry control point and BA teams, other entry control points and, where established, with Command Support are also essential to the effectiveness and safety of BA teams. Accordingly, suitable, sufficient and resilient means of communications should be established at all times.”

4.2.11 the introduction of OGBA has greatly improved the level of BA supervision to that of Technical Bulletin 1/97. At Stage II BA there is now the requirement for an Entry Control Point Supervisor, to oversee and support the Entry Control Operator (ECO).Consideration is also given to the appointment of a Communications Officer at Stage II, their function will be to send and receive messages between BA teams and the BA entry control point.

4.2.12 OGBA Section B-9 ‘Emergency Arrangements’ considers emergency actions comprehensively, examining in detail the provision, equipping and deployment of teams. Subsequently GMFRS has updated all its training materials to reflect this content. As previously mentioned at 4.2.2, All GMFRS training and guidance notes applicable to Breathing Apparatus are currently being ordered into an overarching Breathing Apparatus policy and procedure document for publication in December 2016.

4.2.13 Assessable ‘practical’ training to ensure competency across the operational workforce is also being revised for implementation in the training year commencing April 2017. Assessable ‘theoretical’ training will be commencing earlier through a new IT based learning software system to ensure that the knowledge of the operational workforce relating to BA emergency procedures and communications is attaining the expected levels.

4.2.14 GMFRS has also introduced an enhanced safety capability through the use of specialist teams sent to all incidents where 6 appliances and above attend. This ‘Enhanced Safety Team’, carry specialist equipment such as line communications, battery powered cutting and spreading tools, casualty rescue slings and confined space equipment. In the event of a BA Emergency they will report to the relevant Entry Control Point (ECP) with the appropriate equipment ready for deployment by the Entry Control Point Supervisor in order to assist with the withdrawal of BA crews.

4.2.15 this team will also carry out proactive tasks to improve health and safety on the incident ground. Work is currently being undertaken to review training content, frequency and delivery in the area of BA emergency procedures. The GMFRS Operational Support Team is also exploring alternatives to the existing Emergency Air Supply Equipment (EASE) used by BA emergency teams at operational incidents.

4.2.16 Handing over; It is recommended that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training of the handing over and taking over of roles at incidents to ensure all the key areas of information, including safety control measures, are captured and shared.

4.2.17 GMFRS response: GMFRS acknowledge that following this incident, analysis showed that, the way in which the handover of crucial information and safe systems of work particularly during a period of reliefs, could be improved. In March 2015, GMFRS produced a ‘Service Order’ (internal guidance) ‘Reliefs at Operational Incidents’ that highlights considerations for the IC. This includes managing a phased relief plan to avoid the loss of operational momentum and tactical objectives, such as the interruption of water supplies.

4.2.18 Guidance was issued in November 2014 entitled ‘Handing Over and Taking Over at Incidents’. In order to ensure consistent and accurate handovers, particularly during the relief stage of the incident, the existing Incident Commander now completes a detailed handover form (OPS 50). This is used during the briefing process with the oncoming commander. This form must be signed by both commanders, retained by command support and the confirmation of this handover is included in the informative message notifying the change of command.

4.2.19 since its introduction, the OPS 50 form has become a more familiar and increasingly well utilised part of the handover process. Continued training and operational use will further establish this process as a customary practice. Further inter- departmental work is also underway looking to improve how GMFRS capture role specific handover information outside of the Incident Commander role, e.g. Sector Commander, as well as improving how staged relief handovers are managed.

4.2.20 this ‘Handing Over and Taking Over at Incidents’ guidance document also establishes policy around the taking over of incidents. Now, whenever a more senior officer is mobilised to an incident as the oncoming Incident Commander (IC) they will take command of the incident following a full incident assessment. The only two exceptions to this approach are firstly, when the oncoming IC recognises that   the incident will quickly be scaled down, thereby allowing the current IC to continue as IC. In this situation following a full incident assessment the senior officer must leave the incident. The second exception is when the incident scale has been further increased and another more senior officer has already been mobilised to the incident to take command. Again, in this situation a full incident assessment must still be carried out by the most senior officer.

4.4.21 Risk information; It is recommended that all FRSs should ensure that significant hazards and any safety control measures are:

  • The responsibility of the Incident Commander and should be recorded within each sector, to ensure visibility to all on the fire ground, and
  • Passed/copied for use by the Incident Commander/command team to assist on the analytical risk assessment.

4.2.22 GMFRS response: GMFRS acknowledge that at this incident risk critical information relating to safe systems of work and control measures were not communicated to the appropriate personnel, or captured on the analytical risk assessments (ARA’s).The Risk Assessment/ Hazard Inventory process has been in place in GMFRS since February 2006. Its main purpose is to ensure that all hazards are recorded, made known and acted upon by crews through recording on an OPs 25 form. This form also makes provision for the recording of regular reassessments, any control measures in place and the time at which the hazard becomes controlled. It does not however, constitute a full analytical risk assessment as defined by national guidance.

4.2.23 an internal review of current procedures is underway by the GMFRS Operational Support Team and the Operational Assurance Team, with consideration being given to how the existing procedures can be more closely aligned to the national analytical assessment process. GMFRS is currently reviewing its training and development through its Incident Command Academy to include assessment in the recording of risk critical information on ARA’s during corporate Incident Command training and through promotional processes for all operational staff.

4.2.24 Thermal imaging; It is recommended that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training in the appropriate use of thermal imaging cameras to include the limited extent to which they can be relied upon to measure ambient temperature.

4.2.25 GMFRS response: Following this incident there was concern as to the levels of understanding held by the operational workforce relating to the technical capabilities of the thermal image cameras in use in GMFRS at the time.

4.2.26 GMFRS carried out a training needs analysis in the form of a workforce survey to establish this knowledge and understanding. The survey was conducted by Training and Development Centre staff and completed by 11% of the workforce during   a 7 week period in March and April 2014. The results, coupled with initial accounts from the Oldham St incident, provided clear evidence that a large percentage of operational personnel surveyed did not understand the information provided by a thermal imaging camera within a fire compartment. The results showed that many personnel misinterpreted the temperature readings. This prompted a comprehensive review, upgrade and re-issue of all thermal image camera literature and training packages, with an emphasis on their use in relation to compartment fires.

4.2.27 in 2014, new thermal imaging cameras were introduced, intended for use by Incident Commanders to complement those in use by BA wearers. These cameras provide a full thermo-graphic picture of any property involved in fire, and assist the Incident Commander in formulating a tactical plan.

4.2.28 GMFRS recently introduced a new IT based training system which involves user completion of an assessable test of knowledge. Risk critical questions around the use and capabilities of GMFRS’ thermal imaging cameras will feature in these tests to ensure that the appropriate level of understanding is achieved and maintained by the operational crews. At present, operational personnel in GMFRS carry out training on the thermal imaging cameras at least once every 6 months to maintain competencies in line with Firefighter National Occupational Standards (NOS).

4.2.29 Aerial monitors; it is recommended that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training in the deployment of aerial monitors to ensure the safety of any personnel within the risk area is not compromised.

4.2.30 GMFRS response: GMFRS accept that there is a lack of guidance in the operational arena as to the use of aerial monitors at incidents where breathing apparatus crews are committed to the risk area. This highlights a previously unidentified gap in procedural guidance.

4.2.31 there is limited written guidance in the National Operational Guidance on this subject knowledge was formerly passed on through peer networks and commonly referred to as ‘practical firemanship’. Now that this omission has been highlighted, work is currently underway to create an aide memoire specific to this field (for issue late 2016), which will act as an interim guide. The knowledge to inform this piece of work is being drawn from a variety of sources including other FRSs, appropriate GMFRS departments and operational staff from aerial appliance stations who have practical working experience of this equipment.

4.2.32 this subject matter will be covered in full in the ‘Fires in Buildings’ standard operational procedure (SOP) currently under development by the GMFRS Operational Information Team. The draft SOP will be taken to the internal Operational Information Governance Group for ratification prior to publication. This group contains members of the Health and Safety Committee, including the FBU’s own Health and Safety representative. Following the publication of this SOP, an action card will be created that will replace the interim aide memoire.

4.2.33 7(2)(d) criteria; It is recommended that all FRSs should undertake a review to consider the circumstances in which inspections should be carried out under section 7(2)(d) of the Fire and Rescue Services Act 2004.

4.2.34  GMFRS response: the GMFRS operational risk gathering inspection strategy is based on a risk profiling scoring system. In practice this means that where a premises has a higher risk scoring it will be visited for the purpose of gathering risk information, whereas low risk scoring premises will not. The lowest score (less than 5) will generate a validation check by the GMFRS Contact Centre every 36 months whereas the very highest score (above 20) should generate a visit by an operational crew, and where resources permit, a Fire Safety Enforcement Officer every 12 months. For information, Paul’s Hair World (PHW) is one of over 18,000 commercial businesses on record for the borough of Manchester and this borough is one of 10 boroughs covered by Greater Manchester Fire & Rescue Service. Under this inspection process, as a shop, PHW today scores 8 (low risk), resulting in a validation check by the Contact Centre every 24 months. PHW and its ‘parent’ building does not contain any ‘active’ fire safety measures that would raise the risk any higher than low.

4.2.35 as an example of this risk based approach, significant risks relating to residential high rise premises were highlighted in reports following the Shirley Towers and Harrow Court incidents. Since these reports GMFRS has concentrated on inspecting residential high rise properties and all those properties within the county now have a specific risk record. The same exercise is now being undertaken to gather risk information on commercial high rise properties.

4.2.36 In 2014 all GMFRS operational crews began fire safety training to complement the ongoing 72(d) risk assessment and site specific risk information capturing process. The training themes are:

»  General principles of fire protection
»  The emergency response and fire safety interface
»  The built environment

The initial sessions were delivered by GMFRS uniformed Fire Safety Enforcement Officers however this has now evolved into online ‘webinar’ sessions due to continue into 2017.

4.2.37 following the fire at PHW a 12 month project was established to inspect all the properties in the surrounding area of Manchester. The intended outcome was to reduce the number of fires in non-domestic premises, improve community engagement within the residential sector and to enhance safety measures within the building stock through regulatory compliance and design innovation.

4.2.38 The Coroner also recommended that all the above mentioned steps be undertaken jointly by Fire and Rescue Services and the FBU or other Health and Safety Representatives on the Health and Safety Committees.

4.2.39 GMFRS response: In GMFRS, a task and finish group is working to make improvements in relation to all the above recommendations. Members of this group include a representative of the FBU and also representatives from the GMFRS Health and Safety team. The FBU Health and Safety Representative also attends the GMFRS Health and Safety Committee. An example of joint working between GMFRS and Representative Bodies is provided at 4.3.6 below.

Section 4.3: Other related GMFRS improvements post July 2013

4.3.1 As well as the looking to tackle the areas of concern highlighted by the Coroner, GMFRS have been proactive in developing other advances to improve firefighter safety throughout the organisation since July 2013.

4.3.2 GMFRS updated its ‘Incident Command Policy and Procedure’ document in November 2014 to apply the principles and guidance contained within the current Incident Command National Operational Guidance (NOG). All GMFRS training and guidance notes applicable to Incident Command are currently being reviewed and ordered into an overarching ‘Incident Command Policy and Procedure’ document by the Operational Information Team, scheduled for publication in February 2017.

4.3.3 Incident command; Training and assessments have improved through the development of the XVR software system to ensure all our officers have command competence. XVR is interactive software capable of simulating a wide range of scenarios. It provides high quality training and will develop skills of personnel in a command role such as conducting dynamic risk assessments and risk critical decision making. These skills ensure that Incident Commanders maintain a high level of competency which will help them make better decisions at incidents, where lives and property are at risk. Incorporating ‘joint working’ and ‘joint understanding’ with other emergency services within these simulations has also been instrumental in assisting the understanding of the need for a multi-agency approach. Since July 2013, GMFRS has been externally recognised by the British Quality Foundation for its innovation around the use and development of this XVR system.

4.3.4 Functional role guidance: The guidance in use in July 2013, ‘Functional Officers Roles and Responsibilities’, does not allocate a specific role the responsibility for the organisation of reliefs at a protracted incident. This has since been addressed in an updated set of 13 ‘functional role’ service orders, which have been issued to clearly set out the roles and responsibilities of functional officers. In this document, one of the designated tasks of the Command Support Officer is to ‘manage the Command Support Team’s coordination of reliefs’.

4.3.5 Lessons learnt tracking system; GMFRS introduced the Review of Significant Events Register (RoSE) in 2014. This allows the recording of events whether they occur internally or externally to GMFRS and allows issues to be tracked from their identification to resolution. Previous Firefighter fatalities incidents have always been priority for the organisation, both to learn from and to avoid similar events.

4.3.6 As an example GMFRS worked very closely with the Fire Brigades Union (FBU) to address the areas highlighted by the FBU reports into the fires at Atherstone-on- Stour in 2007 and Marlie Farm in 2006, which tragically claimed the lives of serving firefighters.  The outcome of these reviews was reported through to the Joint Health and Safety Committee (JHSC) with full support given to the outcomes by the representative bodies (Fire Officers’ Association, FBU etc.). It is the duty of the JHSC to scan the wider environment to identify potential risks to staff and to work collectively to ensure that those risks never materialise. The FBU Brigade Secretary publically supported this joint work through to its conclusion in 2015   ensuring that everything possible was done to learn and provide maximum protection for firefighters.

4.3.7 Incident ground radio communications; all appliances have been fitted with new Motorola digital radios and chargers. The project to replace previous radios began in 2012 with rollout in February 2014. Incident Command vehicles and Command Support vehicles were also supplied with new radio repeaters to increase the ability to deliver more robust communications at incidents.

4.3.8 Command appliances; a new command appliance has been purchased to provide enhanced support at operational incidents. This Command Unit (CU) based at Rochdale is mobilised to incidents of 6 pumps and above, and uses new technology to assist in incident command. The two Command Support Units (mobilised to 4-5 pump incidents) based at Hyde and Atherton have been upgraded with similar technology to carry out the same function as the CU. Incident information and command decisions are now recorded on the ‘Vector’ system, a new technology on these appliances that effectively allows all incident records to be held on a remote server.

4.3.9 Electronic decision logging system; GMFRS implemented an electronic decision logging system in April 2014. This is available when the Command Support Room is open or if a command vehicle is in attendance. A new decision logging policy and revised contemporaneous note pads were introduced in 2014. GMFRS officers record key operational decisions and the rationale for those decisions using a variety of ways, appropriate to the level of incident or event being dealt with. This may be through radio messages, written records in contemporaneous notebooks and decision log books, or through the command support function. Where decisions are recorded, so will the rationale for the decision. It is recognised that records will be made where operational discretion or professional judgement is used. The review of the Analytical Risk Assessment (ARA) process will support this decision logging process.

4.3.10 Firefighting equipment; GMFRS acknowledges that improvements in equipment will always be required to ensure the safety of Firefighters and prevent similar fatalities in the future. In 2015 GMFRS introduced the ultra-high pressure cutting lance (UHPL), which has the ability to pierce surfaces to introduce fine water mist into a compartment fire. This limits water damage, improves internal conditions and more importantly in relation to this investigation, reduces the need for Firefighters to enter the building.

4.3.11 In December 2014 the existing black 19 mm diameter hosereel tubing on all frontline appliances was replaced by new yellow 22 mm diameter high pressure tubing. The purpose for this change was to improve fire fighter safety by increasing the flow of water available at the branch to assist gas cooling during compartment firefighting and reduce the physical effort required when moving either 45mm or 70 mm hoselines from one area to another.

4.3.12 PPE; new layered firefighting kit was also introduced in 2014 which was very different to the previous kit. It now comprised of trousers, a mid-layer jacket and a breathable outer jacket that is more ergonomically fitted.

4.3.13 Additional; an Air Unit (commonly referred to as a drone) was introduced in 2015. This can gather imaging data and relay this down to the incident ground to improve situational awareness and inform decision making by the Incident Commander. A new Command Support Room and Business Continuity Management Room has been established at GMFRS Head Quarters. A new inner cordon gateway control incident system was introduced in July 2015. The purpose of this system is to enhance personal safety by ensuring operational personnel and other individuals are appropriately managed when entering the inner cordon during operational incidents.

4.3.14 the full Coroner’s Regulation 28 letter can be seen at Appendix B.

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


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

Taken from; (The Fire Brigades Union, circa 2013).



In May 2016, whilst the inquest was ongoing, the FBU submitted a report to the senior coroner, Mr Meadows. It is the view of the FBU that previous recommendations relating to incidents where firefighter fatalities had occurred could be linked to the Oldham Street incident itself, where Stephen Hunt died. The purpose of this submission was to outline our concerns that these lessons had not been learned. This section contains the full FBU report that was sent to Mr Meadows.



1.1 The Fire Brigades Union in compiling this report for HM Senior Coroner Mr N Meadows, into the death of our member, FF Stephen Hunt, have analysed recommendations from previous coroner inquests into firefighter fatalities or fatalities in fire and assessed whether they remain current and relevant in relation to this inquest.

1.2 The FBU is deeply concerned that lessons from previous inquests may not have been learned by fire and rescue authorities or Government. To undertake such an analysis the FBU has compared those previous recommendations made by either the Fire Brigades Union, London Fire Brigade, Scottish Fire and Rescue Service or the Coroner to those the FBU make in relation to this incident.

1.3 The FBU in assessing previous recommendations that have primarily been made in relation to firefighter fatalities in operational incidents and balancing whether they remain relevant into the circumstances leading to Stephen’s death make the following recommendations, these recommendations can also be found in the body of the report.


1.4 FBU Recommendation 1

That Greater Manchester Fire and Rescue Service (GMF&RS) should provide additional resources to enable their fire safety department to immediately carry out a comprehensive risk based inspection programme within Greater Manchester focusing on, but not exclusively to, the Northern Quarter. This strategy is to include an agreed and comprehensive programme of 7(2)d visits undertaken by operational crews.

1.5 FBU Recommendation 2

That GMF&RS should, as a matter of urgency, establish a formal structure that would allow operational crews to liaise regularly with the GMF&RS fire safety managers, so that both can be fully briefed upon any new or existing buildings in which there are facilities provided for the assistance and safety of firefighters. Where necessary any Site Specific Risk Information (SSRI) about a building that may be of assistance to firefighters should be made available to all crews via North West Fire Control and the Mobile Data Terminals.

1.6 FBU Recommendation 3

That GMF&RS seeks to actively enforce article 38 of the Regulatory Reform (Fire Safety) Order 2005 to ensure that the passive and active fire safety measures incorporated into the building for the protection of firefighters are present and effectively maintained.

1.7 FBU Recommendation 4

That GMF&RS undertake a thorough training needs analysis to identify gaps in firefighter operational knowledge and skills. Furthermore GMF&RS should ensure that all firefighters receive regular training in all aspects of active fi re safety measures including those which are in line with the Fire Service Manual Volume 3 Fire Safety ‘Fire Protection of Buildings’ to make certain that all firefighters are aware of the impact the various active fire safety measures may have on their operational procedures.


1.8 FBU Recommendation 5

That a full and comprehensive review of all radio communication equipment is undertaken as a matter of urgency resulting in such equipment being operationally reliable as far as is reasonably practicable. If communication issues at operational incidents cannot be resolved to a level that is as safe as is reasonably practicable then control measures are adopted as a result of a risk assessment process and promulgated to all operational crew who have a BA wearing role.


1.9 FBU Recommendation 6

That GMF&RS undertake a thorough training needs analysis in relation to the use of Breathing Apparatus, ancillary equipment and procedures, in particular the use of the Thermal Image Camera.


1.10 FBU Recommendation 7

GMF&RS should immediately review and revise all its Breathing Apparatus procedures and bring them into line with the Operational Guidance for Breathing Apparatus promulgated by the Chief Fire and Rescue Advisor on behalf of Government. This review to ensure adherence to this guidance done in conjunction with the representative body safety representatives via the GMF&RS Health and Safety Committee.

1.11 FBU Recommendation 8

GMF&RS IRMP should be revised to ensure that numbers of operational firefighters is sufficient at all times to be able to implement the outcomes of FBU Recommendation 6, specifically in relation to BA Emergency Teams.


1.12 FBU Recommendation 9 That GMF&RS immediately reviews handover procedures with a view to introduce staggered handovers whenever deemed appropriate, with a controlled staged handover procedure to be introduced at all necessary times.


1.13 FBU Recommendation 10

That GMF&RS should immediately revise its Incident Command System and ensure that it corresponds with the Fire Service Manual Volume 2 Fire Service Operations – Incident Command. This review to ensure proper and Analytical Risk Assessments be undertaken in a timely manner and with immediate effect.


1.14 FBU Recommendation 11

That GMF&RS review its Dynamic Risk Assessment training programme, ensuring that it meets the requirements of the Incident Command System and ensure that all operational personnel and supervisory officers receive regular centrally delivered practical, theoretical and refresher training as soon as reasonably practicable.


1.15 FBU Recommendation 12

That GMF&RS review its mobilisation policy to give consideration whether the Incident Command Unit should by policy, be the Unit that assist Incident Command at incidents of protracted and resource heavy nature, such as Oldham Street.


1.16 FBU Recommendation 13

That GMF&RS immediately review its procedures for the use of aerial appliances at operational incidents, particularly for the use of aerial appliances as water towers at incidents where firefighting crews are present within the building. The review to be co-ordinated within the GMF&RS Health and Safety Committee.


1.17 The Fire Brigades Union along with Stephen’s family, would like to place on record the rescue attempts made in relation to Stephen Hunt and FF 1 by all firefighters which by any measure were heroic. The FBU and Stephen’s family are particularly grateful to CM 9, FF 5, FF 22 and FF 25.

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


Coroner’s report (by N, Gibbins) main conclusions;

Taken from redacted PDF version of (Gibbins, 2016)



i.  FF Hunt and FF1 entered a building that was on fire, through the same entrance as several previous teams, with a similar brief. They handed in their tallies, to an officer who then placed them into a control system known as an entry control board. CM6 was the entry control officer and CM1 was acting as safety officer, both had been involved in managing the entry of BA wearers in this sector throughout the incident.

ii.  They were fresh to the incident; they had just come on duty. They took in a hose that they had tested to ensure that they had a suitable supply and pressure of water. They also had a radio that should have enabled them to communicate with officers outside of the fire. They had a thermal imaging camera that would help them identify places with higher They were wearing full firefighting uniform and they had full functioning breathing apparatus sets that incorporated a transmission system passing information to the entry control board (telemetry), and they had automatic distress signal units - ADSU’s.

iii.  The necessary checks and processes prior to entering a building on fire were carried out, in a diligent manner. This is recalled in statements and exemplified by the actions of FF Hunt – whilst checking the flow of water to the hose he twice required the pressure to be increased. This portrays reasonable caution and an appreciation of the task faced. Whilst they had not spoken about the conditions with the last team that had been in that area, they had chance to take in the size of the premises and the nature of its construction, as well as being aware of the time that the fire had been burning.

iv.  They were not shown a plan or drawing of the internal layout. Some plans had been drawn with the assistance of the occupiers. However, the officers committing them felt they made it clear that they were to go to the top of the stairs, just a few metres inside from the open doorway and no The written evidence does not confirm that they were informed that they were not to work to the full time duration of their BA sets.

v.  They went in to fight a fire. Their brief was intended to limit their movements. They searched for the fire, during the search FF Hunt ascended a stair case to the mezzanine level. Being higher in the building this could have been hotter than the lower areas, with higher ambient temperature. Whilst searching FF’s had to rely on feeling their way, as the smoke in this incident was thick enough to completely obscure their sight, in places. Their clothing covers every inch of skin, by design, to prevent harm from flashovers. They have a gauge that tells them how much air they have left. Time is not relevant to them, they calculate the point at which they must turn around and make their way out by monitoring the amount of air used, then they apply a safety margin. FF1 that they regularly monitored their air consumption.

vi.  They follow a system of search and stay together as a team, but at times not in physical contact with each other. One leads, the other supports. They are able to speak to each other. They use a method to help them find their way out, in this instance they would use the hose they took in, as they would know that this will lead them out.

vii.  The position they were briefed to progress to was less than ten metres from the open door that they entered through. CM1 had observed FF's operating in that place throughout the afternoon.

viii.  At 20.00 hrs A/CM3 replaced WM 1 as sector commander.  CM4 relived CM6 as ECO.  CM5 took over from CM1 as safety officer.  At some point CM5 left sector 1 to obtain a tabard to indicate that he was a safety officer. He arrived back at the sector at the time FF’s 25 and 22 (relief team for FF’s Hunt and 1 had come out of the building to report that they had heard shouts for help). This appears to me to be a lot of change happening at the same time, created by the relief being timed to align with the watch changeover for all the appliance based crews. I am not aware of any policy or guidance relating to this, but the break in continuity has the potential to increase risk.

ix.  CM4 was with the ECB some metres away from the doors. It is not clear from the written evidence that I have seen that all critical information was handed forward to him, in particular that the crews were to be deployed for a reduced duration. I note from his statement that he was prompted by FF24 who was operating the pump supplying water to FF Hunt and FF 1 saying that he could not contact them by radio. This prompt caused him to look at the time they had available in their BA cylinders, which leads me to conclude that he was not taking into account the reduced duration. CM4 states that a relief team came to him, rather than saying that he requested a relief team. When BA main control is in operation (now known as BA sector) it is the role of the Main Control Officer to supply reliefs as required. CM4 should have had an emergency crew stood by with him, or been aware of the arrangements for an emergency crew, as they could be at another position if deemed close enough. These points may have been overlooked when statements were made.

x.  FF’s 22 and 25 were committed by CM4 to relieve FF’s Hunt and 1.  It is not stated in the written evidence that they were informed that the team they were replacing were overdue, and that is consistent with CM4 not being aware, or not applying, the reduced duration. FF Hunt and FF1 were not late out according to their cylinder contents, but had been inside for around twenty minutes when the reliefs went in.  If the crew sent in to relieve FF Hunt and FF 1 had been aware of any concern about the time they had been in, they could have been assisting them out rather than relieving them.

xi.  Officers had withdrawn firefighters on several occasions when they were concerned about the fire behaviour. During the period that FF Hunt and FF1 were inside the building there may have been changes in the smoke, in terms of colour and volume, as firefighting tactics changed, deploying a different jet at the front and turning on or off the jets being applied at the rear. There are no reports from officers outside that anything occurred that they should have been concerned about. After each previous withdrawal crews were recommitted, as the access to apply water was limited and the effects of firefighting seemed to be positive. There seems to be no compelling reason to change the status of the incident, to defensive mode.

xii.  FF22 and F25 were committed as a relief crew. They entered and then withdrew at the time that FF1 reports feeling hot and then becoming lost. They had no reason to believe that the team they relieved had not left safely. They were very close to the exit when they passed them. They do not report any significant change in the fire conditions in this time.

xiii.  CM4 believed he had seen the two firefighters who should have been relieved emerge from the building. This was a mistake, he saw FF22 and FF25 who had retreated to inform someone about hearing shouts for help. The board was set up 24m from the door, but it is understandable that two firefighters emerging from a doorway would appear, even close up, like any other two firefighters.

xiv.  CM4 had two radios, one on each of the channels in use, i.e. 1 for command, 3 for BA.  He reports hearing transmissions only on channel 1. The radios have been tested and no technical reason identified for them not to work, other than the potential for the battery to have gone flat. It could be assumed that the loss of radio contact would be a critical issue, and in line with TB 1/97 it should result in emergency action. This matter warrants further explanation.

xv.  The BA sets are provided with a system called telemetry that transmits information from the set to the BA ECB outside. If telemetry fails, the ECO should take action. FF1 telemetry lost contact with the ECB around 8 minutes into the wear period. FF Hunt’s set continued to operate. The working system would have indicated to CM4 that FF Hunt was down to ten minutes’ air remaining, at around 20.30. It is not clear if that was noted by CM4 and if it was, what he did about it.

xvi.  CM4 does not report any other warning being raised apart from the operation of an ADSU, which he believed was being worn by one of the FF’s that he could see outside the building. When he realised that the two FF’s he had seen were not FF’s Hunt and 1 he pressed the evacuation signal on his entry control board.

xvii.  A combination of issues caused SM2 to shout “BA emergency” over the radio.  Firefighters outside of the building became sure that there were FF’s inside close to the entrance at sector 4. This, as well as reports of shouts for help, raised the alarm. CM9 and FF5 had entered through sector 4. They firstly discovered FF1 then FF Hunt. Both received immediate treatment from fire and rescue staff trained in resuscitation, and the ambulance service team that were in attendance to support firefighter safety.


i.  FRAs and strategic managers within the fire and rescue services are responsible for ensuring their personnel are suitably trained and competent to undertake their roles. The Fire and Rescue Services Act 2004 dictates that FRAs must secure the provision of training for their personnel.

ii.  During this investigation attention focussed on the training and maintenance of BA skills/competencies in relation to FF Hunt and FF1 only and not any other areas of  training or other personnel.

iii.  GMFRS use Fire Service Circular 18-2009 (Section 2.10) for guidance on delivering BA training to their personnel. DCLG: Operational Training Guidance – BA superseded this guidance in May 2013. The DCLG guidance explains how FRAs can meet their obligations with regard to BA training and maintenance of competence for their personnel. It states BA wearers should be assessed at least once every two years in an environment that exposes them to heat and smoke.

 iv.  GMFRS confirm that their BA training policy current at the time of the incident was as follows:

  • Compartment Fire Behaviour Training (CFBT) – In July 2013, GMFRS moved from training 100% of the workforce every 12 months to 50% every 12 months. This equates to once every two years for for individuals.
  • Annual BA refreshers - operational personnel attend a one-day BA refresher every 12 months.

v.  FF Hunt joined GMFRS in September 2008 and FF1 in September 2009. They undertook initial recruit BA training and then training in line with current GMFRSs policy to maintain their competence.

vi.  FF Hunt’s last recorded annual BA wear in heat and smoke was on 2 August 2012 and his last recorded BA wear prior to the incident was a training event on 1 June 2013.

vii.  FF1 last recorded annual BA wear in heat and smoke was on 15 April 2012 and his last recorded BA wear prior to the incident was a training event on 6 June 2013.

viii.  GMFRS use a system called iTrent to electronically record training undertaken by personnel.  FF Hunt’s and FF1 iTrent records were analysed as part of this investigation. They complied with GMFRS’s policies, namely; wear BA at least every seven tours of duty or bi-monthly and wear BA in a hot fire compartment every 12 months.


i.  Evidence from pathologists agree that Stephen Hunt suffered from heat stroke.  His body temperature would have increased due to working in a hot environment wearing clothing that hinders heat release from inside.

ii.  Stephen had entered an area of the building above the ground floor, leading a team that comprised himself and FF1.  Stephen climbed higher into the first floor than the other FF.  There was no vent or window from this area, the air temperature is likely to have been very high considering that the fire had been burning for around four hours.

iii.  From the statement made by FF1 they appear to have started to suffer the effects of heat within ten minutes of entering the building. It is not clear whether or not the control mechanism of reducing the duration of the exposure was communicated through the handover period. This may have resulted in the relief team being committed later than could have been the case. There are a number of alternative scenarios that should be considered. If the system of work in operation during the earlier phase had been replicated exactly-

  • The brief was to enter only to the top of the stairs
  • They would have been observed by the safety officer from the doorway
  • They would have been relieved before the full duration of their cylinder

However, a team did enter, effectively relieved FF’s Hunt and 1 but it was after this point that they did not find their way out. The time at which this should have been recognised and acted on requires further analysis.

iv.  Stephen had access to temperature information from a thermal imaging camera. Apart from “feeling hot” FF’s have restricted ability to gauge temperature, as all of their skin is covered by protective clothing. The usefulness of the TIC in helping FF’s understand the environment around them is questionable.

v.  One effect of increased body temperature is that it changes thought processes. As well as feeling extremely tired, judgement can be impaired. This may explain why they missed the top of the stairs that would have led them to the exit. They should have been able to follow the hose out, and the team that relieved them did so. FF’s 22 and 25 report that they felt the effects of the heat very soon after entering the building, but they were inside at the time that FF Hunt and FF1 were seeking the exit. They do not report any significant change in environment, as may have been caused by the use of water jets, or ceasing use of water jets.

vi.  FF1 reports hearing Stephen calling for help on the radio. If his radio had been transmitting, on either channel 1 or 3, all other radios at the scene could have received the message, including the one with his entry control officer. The equipment has been tested, and no significant fault found. There could have been a number of possibilities for this - Stephen may not have actuated the transmission system properly, the signal did not get outside of the building, the set could have been on a channel not being monitored, or the battery could have been flat. The latter two points would be discounted if the appropriate entry control process had been followed, statements say that it was, and there are other indicators that Stephen was very diligent in following safety systems.

vii.  The most obvious means to obtain help in this situation would have been to operate the distress signal unit. There are two methods of actuating the alarm- an automatic system that operates if the wearer stops moving for a short time, and a manual system that requires a button to be pressed. In both instances the unit causes an alarm to be raised on the entry control board, and starts to emit a loud noise from the unit itself. This is to raise the alarm and help rescue teams locate the person in distress.

viii.  Neither Stephen or FF 1 operated their ADSU. Stephen’s actuated after the BA emergency had been raised. FF1 describes that he could not operate his button, he was looking for the key, which is on his tally outside on the entry control board. This suggests that he was so disoriented and confused by the heat stress, he could not do a very basic but critical task. A number of fire fighters could have been close enough to hear a DSU distress signal. FF’s 22 and 25 thought they heard shouts. The level of sound emitted from a DSU and the distinctive tone would have given clarity and most likely an immediate response. I refer to training records later, but note that the operation of a ADSU manually, in distress, is likely to be a once in a career event. If not explained by further evidence, this issue should be considered as a matter of urgency by those responsible for designing training for firefighters.

ix.  There is nothing to suggest that the ongoing firefighting efforts had any significant effect on the environment in the area that they were found in. It is not standard practice to use large jets of water projected from outside, whilst firefighters in breathing apparatus are inside a building. In this instance the risk posed by placing firefighters inside but close to an exit was balanced against the positive effect that water applied from that position had reduced the fire, and the actual impact that applying water was having. Around 12 teams had operated in this position during the incident. The practice was stopped when firefighting tactics changed and then recommenced when it was observed that water from the hydraulic platform jet applied from Oldham Street was not having a significant effect at the rear.

x.  From the written statements that I have seen, I have not been able to plot all actions of those responsible for monitoring the safety of BA wearers in sector 1 during the time that FF Stephen Hunt and FF 1 were committed inside.  The incident commander changed from GM1 to GM3.  The operations commander from GM2 to SM1.  The sector commander from WM1 to A/CM3.  The ECO from CM6 to CM4 and safety officer from CM1 to CM5.  Many of their actions are referred to above, but I have not been able to establish if all opportunities to identify that two firefighters were at risk were recognised and acted on. My opinion may change after hearing verbal evidence.


i.  I have been asked to consider the following issues: -

  • The general fire precautions and adequacy of arrangements for the storage of materials, including flammables, at Paul’s Hair World
  • The cause of the fire
  • Initial management of the fire
  • Fire command and management of operations
  • The decision to commit crews in breathing apparatus
  • The handover/change of shift
  • The decision to commit Stephen Hunt and FF1
  • Any other matters that appear relevant following my consideration of the written evidence

ii.  My analysis of each area is set out in the preceding paragraphs. If a fire had not occurred, he would not have been If the fire had been extinguished quickly, it would not have grown, it may not have spread. There are shops selling products similar to Pauls Hair World in every town. I am not confident that risk assessments are carried out appropriately, bearing in mind the risk posed by substances used in the hair industry.

iii.  The building performed as would be expected of one from that era. A steel frame, masonry walls and concrete floors resist fire very effectively. They also resist firefighters and the application of New shops with un-compartmented spaces over 2000m2 are required to have sprinkler systems. Once this fire had become established it either needed extinguishing or be allowed to burn until all the combustible material was consumed. The initial belief that people may be inside caused the fire and rescue service to act to deal with the fire. Even when the need or likelihood of saving life was passed, the need to protect the remainder of the building and neighbours caused firefighting to continue. Additional exits (that would have also provided an entrance path) could have assisted, but were not likely to be required by current standards.

iv.  Modern firefighting equipment protects the firefighter from the hazardous environment. It also shields their senses from the heat and prevents them from losing heat through normal means. Every inch of skin is covered to prevent harm from a This also means that they are insulated from feeling that the heat is at a dangerous level. Again, technology and equipment can and does assist. Thermal image cameras help identify temperatures. Telemetry built into breathing apparatus can assist those outside to monitor safety margins. Automatic distress signal units not only sound an alarm on the wearer, but also on the entry control board.

v.  The impact of heat stress is potentially the most important learning point. I do not believe that many firefighters would expect two very fit young persons to be affected so quickly, as they would appear to have been in this instance. The impact of heat on normal reactions should be recognised and widely It appears that some technological aids have either not functioned as designed, or have not been operated as required. FF Hunt and FF1 were just a few metres inside the building. Their shouts were heard when some operations ceased. There were several firefighters in BA close by that would have been able to respond earlier if they had been aware that colleagues were in difficulty. Radios and telemetry can be powerful tools, but the one device that should be relied on is the distress signal unit. The ADSU’s provided do not require any action to raise the alarm, both at the entry control board and on the wearer. It does not appear that either FF Hunt or FF 1 operated the button on their unit. The fire that occurred on that day had unusual features, the combination of combustibles, lack of access, thermal insulation and building layout had impact on the firefighting processes. The same could happen again, and potentially even more challenging fires with the current emphasis on thermal insulation and security. Instances might arise where persons are trapped and the decision to commit firefighters is made. Firefighters need to be able to rely on the technology that is provided but they must also have default actions, instinctive reactions, if heat stress is having an effect. There should be no hesitation in pressing the button on the DSU if a firefighter feels any sign that they may need help.


Police report (by West Yorkshire Fire & Rescue Service) main conclusions;

Taken from; (West Yorkshire Fire & Rescue Service, 2014).


Health & Safety Laboratory (HSL) example safety critical finding/notice;

Safety Critical Notice - Operational Use of Thermal Image Cameras


The investigation into the fire at Pauls Hair World, at which Ff Stephen Hunt tragically lost his life, is being investigated by GMP and the HSE. WYFRS is supporting this investigation with the provision of technical advice.

The Gold Strategy for the investigation and the ‘Guidance for the investigation of fire fighter fatality in the workplace’ facilitate the promulgation of information that is deemed to be of a safety critical nature.

As part of the investigation, a number of evidence sources have been reviewed.  These include:

-           Initial accounts (FS1)
-           Witness interviews and statements
-           Photographs from the scene
-           Equipment test reports
-           GMFRS policies and procedures
-           Equipment User Manuals and Technical Specifications

Safety Critical Issue

A review of the evidence gathered as part of this investigation has identified that some personnel in GMFRS refer to the thermal image camera temperature reading when describing the internal and external fire conditions.  Evidence shows that this information has been noted mentally and in some cases recorded during the incident.  Therefore, there is a risk that this practice may influence both the dynamic risk assessment and decision making processes.

Capabilities of the Scott Eagle Thermal Image Cameras

The Scott Eagle Thermal Image Camera in use by GMFRS is capable of measuring spot temperatures only.  The HSL has confirmed that this spot measurement cannot be relied upon as an indication of the temperature of the environment around the user.   An extract from their report is included within Appendix 1.  All GMFRS Scott Eagle cameras have been tested by the HSL and it was confirmed they all work adequately as a measure of spot temperatures, albeit with some limitations.

Capabilities of the Argus 3 and 4 Thermal Image Cameras

GMFRS also operate the Argus 3 and 4 Thermal Image Cameras.  These are capable of measuring both spot and ambient temperatures.  Initial tests carried out by WYFRS and observed by GMFRS suggest that neither the spot nor the ambient temperature measurements should be relied upon as an indication of the temperature of the environment around the user.   This observation has not been verified by an expert on the use of thermal image cameras such as the HSL.

There is also the possibility of confusion between the capabilities of the Argus and Scott cameras in terms of spot and ambient temperature measurements.

Operational use of Thermal Image Cameras

During BA deployment

Evidence from this incident suggests that some fire fighters use thermal image cameras during BA deployments to determine the temperature of the environment inside the building or compartment. 

Also, in certain instances it appears that the temperature reading has conflicted with the users own senses and appraisal of the conditions.  A reliance on the camera temperature over and above their own senses may have a detrimental impact on their safety.  

Recording of temperature readings

During the incident temperature readings were taken and recorded on the Sector 1 Command Board.  The use of a thermal image camera from the outside of the building will not provide a reliable measure of temperatures within the building. 

 New image

Image 1 – Sector 1 Incident Command Board (Record of T.I.C Readings)

Appendix 1

Health & Safety Laboratory (HSL): Report examining Breathing Apparatus, Personal Protective Equipment, Thermal Image cameras and radios associated with fire fighter fatality, Manchester, July 2013

Extract of comments from HSL report following the testing of Scott Eagle Thermal Image Camera:

The Scott cameras tested all seemed to work as intended and gave similar results within a reasonable spread, with most variation at 200oC (approximately 10%).  Compared to the set plate temperature, they tended to read low at 50 and 100oC (to a maximum of approximately 15% and 13% respectively) and read high at 200oC (between 0 and 10%).

The accuracy of temperature measurements by a thermal imaging camera is dependent on it being set to an emissivity value (a measure of the relative ability of a surface to emit radiation) that matches that of the object being observed.  The Flir SC2000 camera used by HSL, and probably the Scott cameras as well, revert to a default value on switch on (but the Flir can be reset to any desired value).  The default value is chosen as a compromise setting that is close to the emissivity of many common objects and is fairly high (0.92 in the Flir case), such as for smoke-blackened wood or cardboard.

Provided the default value is fairly close to the actual object emissivity, the temperatures measured are a reasonable representation of the actual object temperature. It is however not possible to make accurate measurements unless the object emissivity is accurately known and the camera can be set to the same value.  Using the fixed default emissivity value will result in temperature measurements for low emissivity objects, such as shiny or reflective surfaces, being considerably lower than they actually are.  This error is significant at low emissivity values due to a “temperature to the 4th power” relationship on which in this sort of measurement is based.

There will be some absorption of the radiation from the object of interest by any fog, smoke etc. in the line of sight.  The key factor is how absorbent the medium is at the camera’s operational wavelength.  Other factors are density of fogging medium, size and distance of object from the camera, temperature difference (particularly with smoke, which might be quite hot), and camera design.  General purpose cameras operate over a narrow wavelength band that works quite well with mist and smoke, through which they can see much better than visual devices, and are very useful for locating heat sources.  However, there will be some absorption of a non-definable amount, so any temperature measurements will be generally reduced and inaccurate.  Smoke from the burning of some materials may obscure visibility for the camera almost completely.

For military applications some smoke screens are specifically designed to defeat thermal imaging by being very absorbent at the camera wavelengths used. Conversely, some cameras are designed to operate at a specific wavelength so they can actually visualise a particular gas or vapour.

The above discussion indicates that making accurate temperature measurements with thermal imaging cameras is not straight forward and requires specialist knowledge. The Scott cameras tested give an indicated spot temperature for where the cross wire at the centre of the screen is pointed, which could be low if trained on a shiny or reflective object, and will be unrepresentative of the ambient air temperature surrounding the camera or its user. In my opinion the cameras, are very useful for enhanced vision in poor optical visibility conditions, and for locating relative hot spots.  They should not be relied on for accurate object temperature measurement, only qualitative indications of “hot”/“cold”.


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;

Greater Manchester Fire and Rescue Service (GMFRS). 2013. Fatal accident investigation report. Paul’s hair and beauty world, Oldham Street, Manchester. [pdf]. Available at [Accessed 7th May 2017]. GMFRS.

FBU Incident Report/s;

The Fire Brigades Union. (circa. 2013). Oldham Street incident 2013 the death of firefighter Stephen Hunt. [pdf]. Available here.  The Fire Brigades Union (FBU). 

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

Health & Safety Laboratory (HSL). (circa 2013) Report examining Breathing Apparatus, Personal Protective Equipment, Thermal Image cameras and radios associated with fire fighter fatality, Manchester, July 2013. [pdf] not currently accessed. Health and Safety Executive (HSE).

Greater Manchester Police Incident Report/s;

West Yorkshire Fire & Rescue Service. (2014) Firefighter fatality investigation Pauls Hair and Beauty World Oldham Street Greater Manchester. [pdf] Accessed 1st August 2016. Greater Manchester Police.

North West 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 regulation 28 notices;

Gibbins, N. (2016) Investigation into a fire Plaintree House 21-23 Oldham Street Manchester Saturday 13th July 2013. [pdf] Accessed 1st August 2016. HM Coroner, N, Meadows & Gib Fire Risk Services Ltd.

Meadows, N. (2016). Regulation 28; Report to prevent future deaths. [pdf] Available at  [Accessed 8th June 2016].

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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