Incident directory

2010 - Shirley Towers

06/04/2010

Country:

UK

  • Building Fires

Severity:

Fatal

Description

Date of event

6th April 2010                

Time of event

Approximately 20:10 HRS (INITIAL CALL)

Name of premises

Shirley Towers (Flat 72)

Location

Church Street, Shirley, Southampton.

Service area

Hampshire Fire and Rescue Service (HFRS).

Nature of incident

Fire

Property type

High Rise

Premises use

Dwellings.

Construction type and materials

Steel frame and concrete, ‘scissor’ design maisonette style.

Occupancy

Mostly social and limited private sector.

Fire source and location of fire

Curtain material on top of light bulb in living room in 9th floor flat.

Synopsis

Brief Synopsis

Hampshire Fire and Rescue Service (HFRS) were called to a fire on the 9th floor of Shirley Towers at 20:10 on the 6th April, 2010. The pre-determined attendance (PDA) of 5 pumps, special equipment unit (SEU), an aerial appliance and 2 flexi duty officers was sent.

On arrival the incident commander (IC) made pumps 6. There was some confusion over the layout and floor numbering of the building. Crews were initially taken to the fire floor by a ‘responsible person’ despite requesting to be taken to 2 floors below the fire floor. The fire was not persons reported. 2 teams of 2 breathing apparatus wearers (BA) were committed with one team, red 1, committed at approximately 20:30 and the other team, red 2, committed a short time later. Both teams were using hoses connected to the dry riser on the 7th and 5th floor respectively (HFRS, Unknown date).

Due to the thick black smoke, Red 1 failed to see the fire in the living room and passed by it, without attempting to extinguish it while on a right hand lay to the upper floor of the flat. When the second BA team (red 2) got to the flat entrance and realised their hose was not long enough, they then followed the other BA teams (red 1) hose, effectively entering the flat without their own water supply and passed by the fire compartment (living room) looking for the other BA team to assist them. Upper floor bedroom windows were opened by red 1 BA team and this combined with the front room window failing caused the fire to rapidly develop while the 2 BA teams were above the fire. Surface mounted, plastic cable trunking failed, enabling electrical cables to dangle. Fire-fighters got caught in the cables. 2 fire-fighters (red 2) were killed and 2 (from red 1) were nearly killed, narrowly escaping from the upper fire exit that was available from the top of the scissor design flats (HFRS, Unknown date).

Photo 1

Courtesy of Hampshire Fire and Rescue Service (HFRS)

 Photo 2

Courtesy of Hampshire Fire and Rescue Service (HFRS)

Photo 3

Courtesy of Hampshire Fire and Rescue Service (HFRS).

Photo 4

Courtesy of Hampshire Fire and Rescue Service (HFRS).

Photo 5

Upper floor bedroom windows, flat 72. Courtesy of Hampshire Fire and Rescue Service (HFRS).


Photo 6

Front room of flat 72. Courtesy of Hampshire Fire and Rescue Service (HFRS).

Photo 7

Courtesy of Hampshire Fire and Rescue Service (HFRS).

Photo 8

Courtesy of Hampshire Fire and Rescue Service (HFRS).

Photo 9

Fallen cables in Flat 72. Courtesy of Hampshire Fire and Rescue Service (HFRS).

Photo 10

Fallen cables on the 11th floor. Courtesy of Hampshire Fire and Rescue Service (HFRS).

Photo 11

Fallen cables on the 11th floor. Courtesy of Hampshire Fire and Rescue Service (HFRS).

Photo 12

Courtesy of Hampshire Fire and Rescue Service (HFRS).

Main findings, key lessons & areas for learning

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

Taken from Hampshire Fire and Rescue Service. (unknown date). Report of the Hampshire Fire and Rescue Service investigation into the deaths of Firefighters Alan Bannon and James Shears in Flat 72, Shirley Towers, Church Street, Southampton, SO15 5PE, on Tuesday 6 April 2010.

--subaccordion--

Chapter 8: Significant Conclusions

8.1 During the HFRS investigation a number of issues were identified that contributed to the events leading to the deaths of Firefighters Bannon and Shears. The impact of these issues ranged from minor to significant.

Those issues viewed by HFRS as most significant are detailed below.

8.2 Following the HSE investigation, a detailed letter was sent to HFRS (see Appendix M) setting out matters the HSE wished HFRS to consider to prevent a reoccurrence of a similar incident. A summary of the actions identified, and the completion date of actions taken to address these recommendations, can be found at Appendix N. For the avoidance of duplication the matters set out within those Appendices are not repeated below.

8.3 Conclusion 1: Failure to gather and include vital information in mobilising message: Some important information received from the first 999 caller providing details of the fire location was not passed to the responding resources. This omission led to:

  • The IC assuming that Flat 72 was on the seventh floor and planning to set up the Bridgehead on the fifth floor instead of the seventh floor. In fact, by mistake and contrary to the instructions of the IC who gave instructions for the Bridgehead to be positioned on the fifth floor, the Bridgehead was set up correctly on the seventh floor but throughout the incident most personnel were confused about the actual floor they were on.
  • The initial crews not being informed that flames had been observed in the lounge leading them to search the flat to locate the fire.
  • Confirmation was not sought from the caller that all persons were out of the flat.

Please refer to Finding 3.1 and Recommendations 3.1.1, 3.1.2 and 3.1.3.

8.4 Conclusion 2: Failure to locate and extinguish the fire before moving above it: The first BA crew that entered Flat 72 did not locate the fire in the lounge or extinguish it before ascending the stairs to the upper floors. Despite carrying a TIC they chose not to use it. The second BA crew did not report locating the fire and ascended the stairs following the hose line of the first BA crew. This omission led to:

  • The initial crew not locating the fire in the lounge before ascending to the upper floors.
  • The fire being left unchecked and developing significantly below the ascending crews.
  • Both crews including the second crew who were not carrying any firefighting media, being exposed to intense heat from the developing fire below them.

Please refer to Finding 2.5 and Recommendations 2.5.1 and 2.5.2.

8.5 Conclusion 3: Unauthorised ventilation of Flat 72: The first BA crew opened windows in the bedrooms above the lounge to aid ventilation. This act would have allowed the passage of heated air to flow upwards (and past the second crew) and exhaust out of the open window.

Please refer to Finding 2.13 and Recommendations 2.13.1 and 2.13.2.

8.6 Conclusion 4: Declaration of a BA emergency: Following a loss of communication with Red Team 2, Red Team 1 arrived back at BA Control in a distressed state at approximately 20:46. These factors should have prompted the initiation of a BA emergency. Communications with Red Team 2 could not be re-established and subsequent teams indicated a developing fire.

Red Team 2 ‘time of whistle’ was noted as 21:01. Red Team 5 reported by radio hearing an Automatic Distress Signal Unit (ADSU) at 21:08 hours at which time a BA emergency was instigated. The delay in instigating the BA emergency meant that (assuming air consumption matched projections) the cylinder of Ff Shears’ BA set would have expired three minutes later and almost certainly before assistance could be rendered.

Please refer to Finding 4.4 and Recommendation 4.4.1.

8.7 Conclusion 5: Fire resistant cable supports: Surface mounted electrical cabling was encased in plastic trunking which failed when exposed to heat so releasing the cables. These cables then became a hazard to firefighters. Ffs Bannon and Shears were both entangled in cables when located. The Harrow Court Fire Rule 43 letter only made recommendations regarding fire resistant cable supports for fire alarm cabling.

Please refer to Finding 2.8 and Recommendations 2.8.1, 2.8.2 and 2.8.3

8.8 Conclusion 6: Protocol when cables fall or are likely to fall: BA crews encountering fallen cables had no means of self extrication, eg, insulated cutters. Cables fell between the cylinder and the BA set back plate making it extremely difficult to remove without assistance. Since the incident HFRS has incorporated a strap on the cylinder cover to reduce the risk of cabling becoming trapped between the cylinder and back plate. Insulated cutters have also been issued to every BA set.

Please refer to Finding 2.8 and Recommendations 2.8.1, 2.8.2 and 2.8.3

8.9 Conclusion 7: Signs for assisting in fire situations: Following a previous fire, individual flats were marked to denote their number and whether the flat was an up flat or down flat. The markers were positioned at the top right hand of the flat door. During this incident, and as a result of heavy smoke logging, the signs were totally obscured rendering them ineffective.

Please refer to Finding 2.17 and Recommendation 2.17.1

Section 2: Findings and Recommendations

Introduction

This section details the findings and recommendations of the AIT. These are divided into eight groups with specific detail for each itemised heading under individual recommendations.

As the HFRS AIT investigation proceeded, a number of issues emerged. Once established and proven, these emerging issues were passed to the Organisational Improvement Steering Group (OISG) for action. Those issues forwarded and resolved are marked with an asterisk *. Those items forwarded to OISG but awaiting resolution are marked as #. The timings in brackets are the times the issue appears in the chronology.

A multi agency ‘Gold’ level group was established in response to the incident (led by HC). This group consisted of representatives from HC, HFRS, HSE and Southampton City Council (SCC). This group considered strategic issues outside of the investigation process including matters of public and firefighter safety such as the risk from fallen cables and spalling of concrete. These two risks were submitted to CFRAU for wider national circulation.

These findings and recommendations do not seek to imply criticism of any individual or their actions, but focus on procedures and practices to improve safety on the incident ground.

Index

1 Personal Protective Equipment

1.1 Wearing of appropriate PPE (20:11:50)*

1.2 Shrinkage of firefighters gloves (20:48, 21:57)*

1.3 Identification on the fireground.*

1.4 Recognition of temperatures in fire compartments (20:48, 21:57)*

2 Operational Procedures

2.1 Identification and use of fire lift (20:19)*

2.2 Use of thermal imaging camera (20:35)*

2.3 Familiarisation and pre-planning (20:14:52)*

2.4 Firefighting jets*

2.5 Firefighting and search and rescue (20:35 (x2), 21:38)*

2.6 Provision of operational risk information (20:15)*

2.7 Forced entry of residents’ flats*

2.8 Displaced cables from surface mounted plastic trunking (20:40)*

2.9 Spalling of reinforced concrete roof structures (20:46)*

2.10 Presence of asbestos in premises*

2.11 Resuscitation equipment (21:27)*

2.12 Acquisition of information at incident scene (20:18)*

2.13 Ventilation at fires (20:38)*

2.14 High rise incidents - list of equipment to be carried aloft (20:15)*

2.15 Gas cooling using pulse spray (20:43, 21:11)*

2.16 Deployment of personnel into hazardous locations (20:57, 21:04)*

2.17 Marking of flats (21:23)*

2.18 Maintenance of fire resisting structures around flats (21:09)*

2.19 Use of Positive Pressure Ventilation (PPV) during firefighting operations (21:15)*

3 Communications

3.1 Acquisition of information from 999 callers (20:09, 20:11, 20:14, 20:21, 20:26, 20:34, 21:12)*

3.2 Provision of fire survival advice (20:35)*

3.3 Rescue of persons receiving fire survival advice (20:50, 21:15)#

3.4 Use of mobile telephones at incidents (20:14:29, 22:00 )*

3.5 BA set data readings (20:50)*

3.6 Silencing of fire alarm (21:08)*

3.7 Informative messages (20:50)*

3.8 Verification of fireground information from ‘non Control Point sources’ (21:12, 22:03)*

3.9 Inappropriate communication procedures (22:12)*

3.10 Hand held radios (20:40)*

4 Breathing Apparatus Procedures

4.1 Availability of BA control board (21:12 , 21:20)*

4.2 Overwriting of BA control board (20:30)*

4.3 Instigation of Stage 2 procedure (20:26, 21:03, 21:12, 21:20)*

4.4 Initiation of a BA emergency (20:48, 20:49, 21:01, 21:06, 21:12)#

4.5 Use of BA wearers (21:35)*

4.6 Fluctuations in air consumption by BA wearers (20:31)*

4.7 Effectiveness of ADSUs (20:52)*

4.8 Briefing and debriefing of BA crews (20:26, 20:28, 20:30, 20:32, 20:48, 21:22)*

4.9 Communication between BA teams (20:33)*

4.10 Condition of BA control boards (20:30)*

4.11 Provision of a TIC for use by an emergency team (20:41)*

4.12 Supervision and support of the BAECO (21:03)#

4.13 Provision of communication equipment for BAECO (21:20)*

4.14 Recording of information on BA control board (20:30, 21:08)#

4.15 Adequacy of BA board to record details of incident (20:37)#

4.16 Relief of BA crews prior to their time of whistle (20:51)#

5 Training and Competence

5.1 Personnel training records*

5.2 Interpretation of information as part of the dynamic risk assessment process#

Incident Command and Control

6.1 Functional command communications (21:40)*

6.2 Incident command qualifications*

6.3 Accurate record of Contact Point and current Officer in Charge (20:33, 20:40, 21:37)*

6.4 Briefing of officers/appliances en route to incident (22:03)#

6.5 Booking mobile to and in-attendance at incidents (20:40, 22:03)*

6.6 Transfer of information between on-scene Command Points (21:19, 21:31)*

6.7 Recording of information in the Control Log (21:47)*

6.8 Implementation of Search Sector (20:56)*

7 Mobilisation Procedure

7.1 Pre-determined first attendance (20:14:29)*

8 Organisational Policy and Procedures

8.1 Health and safety near miss reports (20:40)*

8.2 Service Orders*

8.3 Debrief reports*

8.4 Archiving of reports into significant Incidents*

 

1 Personal Protective Equipment (PPE)

1.1 Wearing of Appropriate PPE

Finding

CCTV images showed a number of HFRS personnel not wearing full personal protective clothing during the incident, notably helmets and in some cases fire tunics. Service Order 7/4/1 requires the wearing of PPE at incidents to provide wearers with protection from the prevailing hazards. The absence of helmets at this incident is of particular concern because it was a high rise incident with debris and glass falling from the ninth and eleventh floors. A radio message from Command 1 (command and control vehicle) to the Ground Floor Command Support at 21:25 identified the hazard of falling debris, and requested that it be factored into the risk assessment.

Evidence source: Southampton CCTV and HFRS Command 1 tape.

Recommendation 1.1.1

That all personnel should be reminded of HFRS policy regarding the need to wear their full PPE at incidents or on the drill ground. Supervisory officers have a duty to ensure all personnel wear the appropriate PPE.

1.2 Shrinkage of Firefighters’ Gloves

Finding

Following the incident it was identified that some firefighters’ gloves had shrunk in size, in some cases by as much as a third, which prevented them from being re-worn. The structural integrity of the gloves was not affected by the reduction in size.

Evidence source: HSL report and AIT note for file.

Recommendation 1.2.1

That the manufacturer be appraised of the situation and asked to comment. All personnel be reminded of HFRS policy regarding the need to routinely and regularly monitor and inspect the condition of their firefighting gloves both for structural integrity and correct size and record this check within their PPE log book.

Recommendation 1.2.2

That UK fire and rescue service procurement officers are informed of this effect, with a view to their consideration in any future glove procurement process.

1.3 Identification on the Fire Ground

Finding

When viewing CCTV images, considerable difficulty was encountered in the identification of some personnel. The faces of personnel were often hidden or obscured by helmets and the collar mounted station identifying lapel badges obscured by the wearing of tabards, BA sets and/or the carrying of equipment.

Evidence source: Southampton CCTV.

Recommendation 1.3.1

That consideration should be given to improving the individual identifiers on personal protective clothing, for example by adding station and/or personnel numbers on the back of the fire helmet.

1.4 Recognition of Temperatures in Fire Compartments

Finding

It became apparent during the investigation (and indeed from other incident debrief reports) that during the incident, temperatures rose rapidly to the point that the safety of firefighters was endangered.

Evidence source: Steki’s debrief report.

Recommendation 1.4.1

That consideration should be given to providing firefighters with a method of identifying ambient working temperatures.

Recommendation 1.4.2

That HFRS should review its operational training with regard to procedures for dealing with working in excessive temperatures.

2 Operational Procedures

2.1 Identification and Use of Fire Lift

Finding

CCTV footage showed that there was some misunderstanding about which of the two lifts had been designated as the fire lift. This confusion led to some personnel using the non designated lift. During the incident a firefighter was assigned to act as the lift operator for the designated fire lift, however, this firefighter did not remain with the lift for the duration of the incident. The lift was absent from the ground floor for significant periods of time. Due to confusion over which floors the fire and the Bridgehead were situated on, the lift operator had been instructed not to proceed higher than the fifth floor. (CCTV footage shows the lift unoccupied and stationary on the fifth floor for extended periods). During the incident it was noted that all personnel taken aloft by lift, many of whom were dressed in BA, were dropped off at the fifth floor and required to gain access to the Bridgehead on the seventh floor via the stairway.

Evidence source: Southampton (Shirley Towers) CCTV 047R and 048R.

Recommendation 2.1.1

That consideration should be given to ‘marking’ the designated fire lift appropriately during high rise incidents and including this procedure in a revision of Service Orders. Further consideration should be given to providing a magnetic sign to be placed in the lift adjacent to the operating buttons on which the Bridgehead floor is clearly indicated.

Recommendation 2.1.2

That consideration should be given to designating a lift operator equipped with direct communications to the Sector Officer Ground Floor (Command Support) and the Sector Officer located at the Bridgehead (Command Support).

Recommendation 2.1.3

That the procedures for using lifts at high rise incidents should be reinforced and these procedures practised to ensure they are fully embedded.

2.2 Use of Thermal Imaging Camera (TIC)

Finding

TICs are used to detect heat differentials and can identify these through smoke. The use of a TIC assists firefighters to speedily locate casualties, the fire and any hot spots. Procedures dictate that the first crews committed should take a TIC with them to assist with casualty location and fire attack. The first crew committed to this incident did carry a TIC but did not use it to locate the fire. Post incident interviews revealed that some firefighters were of the opinion that TICs were only to be used for casualty location. Post incident trials revealed that TICs can be used to locate fallen cables.

Evidence source: HFRS witness statement Y1 (61).

Recommendation 2.2.1

That personnel should be reminded of the need to carry and use the TIC wherever hazards are likely. It is further recommended that training exercises, incorporating the use of TICs, are used to embed their use at incidents where visibility is poor.

2.3 Familiarisation and Pre-planning

Finding

The construction of Shirley Towers (one of three of its design in Hampshire) is unusual and complex and can lead to disorientation for those not familiar with the design. The layout of the flats can best be described as a scissor design, with individual flats situated across three floors. Entrances to adjacent flats lead either upwards (up flat) or downwards (down flat). An up flat has an emergency exit two floors above the entrance, eg, Flat 72 has its entrance on the ninth floor with an escape door situated on the eleventh floor, whereas a down flat accessed from the ninth floor will have its escape door on the seventh floor. Flat numbering bears no relation to the floor number.

Following a previous fire, all entrances to flats were marked individually to denote whether they were an up or down flat.

Understanding the flat/floor layout and the unusual design is critical to an IC when deciding the correct floor on which to establish the Bridgehead. It is apparent that initial deployment of crews was made without precise knowledge of which floor the fire was on (the first caller provided full and accurate fire location information to Fire Control) and therefore the correct floor on which to establish the Bridgehead. This information was not passed to responding resources. 

Evidence source: HFRS witness statements and HC video of scene.

Recommendation 2.3.1

That for the three tower blocks with this unusual design, Fire Control include flat, floor and escape door information on the Command and Control database. This will permit this important information to be passed to the attending resources and will ensure that attending ICs are aware on which floor the lowest access point to each flat is located. This will also enable Fire Control to provide more accurate fire survival advice to residents and identify the residents’ location relative to the fire and pass this information on to the IC.

Recommendation 2.3.2

That HFRS should review its procedures for ensuring personnel are familiar with potential property risks they might encounter.

Recommendation 2.3.3

That the IC establish precisely the lowest access level to the incident and from this the most appropriate floor for the Bridgehead before deploying crews.

2.4 Firefighting Jets

Finding

The Bridgehead was set up two floors below the incident, ie, on the seventh floor, with the incident on the ninth floor. Initially Red Team 1 attempted to set into the dry riser on the ninth floor but were unable to open the dry riser door. Accordingly the first hose line consisting of three lengths was set into the dry riser outlet on the seventh floor. The second line, also of three lengths, was set into the dry riser on the fifth floor – this second line was designated as the safety jet, but was of insufficient length to be of practical use.

Red Team 2 ran a line of hose from the dry riser on the fifth floor, which reached to the ninth floor. Red Team 2 approached the affected flat but on discovering that their hose line was not long enough to gain full entry, left the jet outside the flat. They then followed their brief of hose managing Red 1 and entered the flat.

Evidence source: HFRS witness statements.

Recommendation 2.4.1

That personnel are reminded to keep hose lines as short as possible to ensure they work at optimum efficiency. Precise and accurate information regarding the location of the fire should be sought before setting into the dry riser at the most appropriate floor.

Recommendation 2.4.2

That personnel should be advised of the need to ensure sufficient hose is laid out to permit safe access to the incident. Where, for whatever reason, there is insufficient hose available, consideration should be given to not entering the incident until the line has been extended.

Recommendation 2.4.3

That all personnel be reminded of HFRS policy that a safety jet must be available and in position before a firefighting team is committed to the fire compartment. It is vital that this jet is of sufficient length to reach every part of the premises in question.

2.5 Firefighting and Search and Rescue

Finding

The initial crews entering Flat 72 did not locate or extinguish the fire in the lounge before turning right and ascending the stairs to the bathroom and the bedrooms beyond. The fire developed in the lounge behind them and spread to the adjacent kitchen.

Evidence source: HFRS witness statements and external Southampton CCTV.

Recommendation 2.5.1

That HFRS should review the training and guidance given to personnel with regard to:

  • The importance of fully extinguishing or controlling fires before proceeding past or above the fire scene.
  • Choosing the most appropriate and methodical search patterns, eg, area by area, room by room or floor by floor.
  • In the specific case of scissor designed flats, procedures and training should ensure that up flats are searched to the left and a right hand search adopted for down flats, unless other specific considerations apply. This will ensure full coverage of the lounge and kitchen areas.

Recommendation 2.5.2

That personnel should be reminded of HFRS policy regarding the importance of keeping the BAECO fully informed of their whereabouts whilst committed to the incident. This is particularly important where a change of level is being contemplated by BA Crews. This should be emphasised during training.

2.6 Provision of Operational Risk Information

Finding

Operational risk information is available to responding crews in either a Premise Inspection Card (PIC) format (hard copy on appliances) or in the new Site Specific Risk Information (SSRIs) files accessible via a Mobile Data Terminal (MDT) in the appliance cab. In his statement CM Clark stated that he had sought information from the MDT but found that information relating to Shirley Towers had not yet been added, there was then insufficient time to access the PIC before arrival at the incident.

Evidence source: HFRS witness statements.

Recommendation 2.6.1

That ICs are reminded of HFRS policy regarding the importance of obtaining all relevant information on the risk/premise being attended.

Recommendation 2.6.2

That operational training regularly incorporates the use of the risk information carried on appliances, so embedding its use at incidents.

2.7 Forced Entry of Residents’ Flats

Finding

Control tapes reveal that Fire Control were aware, from conversations with residents via telephone, that HFRS crews were breaking into flats by forcing entry.

Evidence source: HFRS control tape 12.

Recommendation 2.7.1

That HFRS crews checking the safety of residents should try and ascertain if there is anyone in the flat before forcing entry. Similarly Fire Control, who are in contact via telephone with residents, should advise them to open the door when the HFRS crew knock on the door. This will save valuable time and prevent unnecessary damage.

2.8 Displaced Cables from Surface Mounted Plastic Trunking

Finding

During firefighting operations it was noted that surface mounted plastic cable trunking (installed in Shirley Towers post original build) had softened or melted as a result of the fire in Flat 72. This trunking carried a variety of cables and was present in every room of the flat and also in the common areas of the building. Where the trunking had softened or melted it allowed the cables laid within it to fall free. Where the trunking had crossed doorways the displaced cables had fallen across the doorway often forming an impenetrable barrier. The cables are unlikely to have been very visible in the smoky conditions prevailing during firefighting operations. Post incident trials have shown that cables are visible with the use of a TIC.

Evidence source: HC video of scene, HFRS witness statements and HFRS near miss reports.

Recommendation 2.8.1

That HFRS should contact local housing authorities (and private landlords where deemed appropriate) and share with them the potential problems such installations can bring in the event of a fire. HFRS should request from them the following:

  • The location of all buildings where surface mounted plastic cable ducting has been installed.
  • A programme of works to install fire resistant cable ties to prevent cable displacement in the event of a fire.
  • An agreement to remove redundant trunking and cabling where technology means they are no longer required (eg, replacement wireless installations).

Recommendation 2.8.2

That HFRS should ensure that personnel are aware of the likelihood of encountering such installations and training programmes undertaken to practice procedures for dealing with displaced cabling. Training exercises should include the use of TICs.

Recommendation 2.8.3

That HFRS should consider making representations to seek amendment to BS 7671:2008 the IEE Wiring Regulations and/or the Building Control Regulations to require external cabling to be secured with metal cable ties to prevent detachment in the event of fire.

Recommendation 2.8.4

That HFRS should consider the issue of insulated electrical cutters to BA crews to ensure wearers have the equipment to hand should they become entrapped in fallen cables. Investigations should be undertaken to assess options to prevent fallen cables from becoming entangled in BA sets.

2.9 Spalling of Reinforced Concrete Roof Structures

Finding

During the course of the fire, several large pieces of the reinforced concrete roof structure in the kitchen were noted to have broken loose and fallen to the floor. This phenomena is known as spalling and is a well known feature of reinforced concrete in fire situations. Normal firefighting tactics for addressing this hazard are for firefighters to position themselves in the doorway, or other safe location, and to hit the ceiling with a jet. This serves to hasten any spalling and remove the hazard of concrete falling on the firefighters post entry.

Evidence source: HC video of fire scene.

Recommendation 2.9.1

That firefighters are reminded of HFRS policy regarding safe entry procedures and practical training exercises undertaken to embed these practices.

2.10 Presence of Asbestos in Premises

Finding

Following the incident at Shirley Towers, HFRS was informed by SCC Health and Safety Adviser that asbestos was present in the structure. It was felt that the risk would have been negligible during firefighting operations and immediately after the incident because the water applied to the flat would have damped down any loose fibres.

Evidence source: SCC Health and Safety Adviser.

Recommendation 2.10.1

That HFRS should review the SSRI it holds on Shirley Towers (and similar structures).

2.11 Resuscitation Equipment

Finding

HFRS operational procedures do not include the provision of emergency resuscitation/air provision equipment for use by BA wearers carrying out rescues. The first BA emergency team entered the flat having been tasked with rescuing Red Team 2. They did not take with them any means of providing an air supply to the missing firefighters despite their entry to the flat being several minutes after Red Team 2’s projected time of whistle.

Evidence source: HFRS witness statements.

Recommendation 2.11.1

That HFRS should review its policy, procedure and equipment for rescuing persons from irrespirable atmospheres.

2.12 Acquisition of Information at Incident Scene

Finding

Information detailing the fire floor, the nature and location of the fire was passed by the initial 999 caller to Fire Control, however this was not included in the mobilising messages to the first attending appliances. On arrival the IC requested that the warden take them to two floors below the Fire Floor. Despite this request, the warden took them to the Fire Floor and as the IC exited the lift on the ninth floor (Fire Floor) the warden pointed out the occupier of the affected flat, Mr Mem Pub 1.

The IC had the opportunity to question Mr Mem Pub 1 and elicit further information pertinent to the incident, eg, were there any persons left in the flat, where was the fire, what did the fire involve, etc? This opportunity was missed.

Notwithstanding any information passed by Fire Control, the IC, supported by his/her crew, should elicit all pertinent information from those at the scene before deciding his/her strategy and committing resources.

Evidence source: HFRS witness statements.

Recommendation 2.12.1

That HFRS should reiterate to ICs the importance of gathering all pertinent information (and validating information passed in the mobilisation process) at the incident scene prior to deciding a strategy or committing resources. The occupier of the premises is likely to be a key information provider.

Recommendation 2.12.2

That HFRS should ensure training exercises are conducted that demonstrate the importance of gathering information at the scene prior to the allocation and deployment of resources.

2.13 Ventilation at Fires

Finding

National Generic Risk Assessment 3.2, Version 2, September 2008, Fire Service Manual, Volume 2, Fire Service Operations, Compartment Fires and Tactical Ventilation, and HFRS Lecture Pack R 3.6, Ventilation, provide guidance on the issues governing ventilation at fires. They state that ventilation of a fire scene should only be conducted on the instruction of the IC. Where crews already committed feel it necessary to carry out ventilation, Service policy states that they must seek permission of the IC before carrying out any ventilation.

The initial crew (Red Team 1) committed to Flat 72 were tasked with locating and extinguishing the fire. Ascending the stairs within the flat they reached the bedroom level (the highest point of the flat) and had not located the fire (which unbeknown to them was burning in the lounge and kitchen below them).

Red Team 1 took the decision to open the windows in both bedrooms. They did not request permission from, or inform the IC of this action. In their statement they accepted that this was contrary to policy.

Evidence source: Fire Service Manual Volume 2, Fire Service Operations, Compartment Fires and Tactical Ventilation, HFRS Lecture Pack R 3.6, Ventilation, HFRS witness statement Y1 (59).

Recommendation 2.13.1

That HFRS should review its policy and procedures to ensure guidance on the carrying out of ventilation by firefighters is clear and unambiguous and covers all forms of ventilation conducted by firefighters, ie, positive pressure and natural.

Recommendation 2.13.2

That all personnel should be reminded of HFRS policy regarding inherent dangers of unauthorised/uncontrolled ventilation at fires. Training exercises should incorporate the use of ventilation practices and the conditions for its usage.

2.14 High Rise Incidents - List of Equipment to be Carried Aloft

Finding

The first crew attending Shirley Towers carried with them certain equipment in a High Rise Bag. Service Order 7/4/1 Para 2.1 (First Pump Duties of Crew) lists the equipment that should be taken to the Bridgehead. Several significant items were omitted in the equipment carried aloft including breaking in tools, an axe, a line and a first aid kit.

Evidence source: HFRS witness statements.

Recommendation 2.14.1

That an aide-memoire is included on the appliance to remind crews what equipment should be taken aloft. This could be a simple list on the vehicle or perhaps a listing sewn onto the high rise bag itself.

2.15 Gas Cooling Using Pulse Spray

Finding

During the incident BA firefighting teams were presented with a developing fire within the flat. A number of teams (who were initially concerned about creating worsening conditions by generating steam) tried to control conditions using a ‘pulse spray’ approach. This approach continued despite a crew trapped above them and other crews attempting to proceed up the stairs to rescue them.

Pulse spraying is a tactic adopted to cool hot gases and reduce the likelihood of a flash over. It involves the use of short pulses of water in spray form being deployed into the area just below the ceiling.

This application of extinguishing media is not directed at the fire itself which will continue to grow generating heat, hot gases and smoke. This generation can increase as long as fuel and oxygen are present in sufficient quantities. In Shirley Towers, this generation increased considerably to the point that life could not be sustained in the areas above the fire.

Despite frustration that the pulse spray approach was having little effect on the fire, crews did not change this tactic.

Evidence source: HFRS witness statements.

Recommendation 2.15.1

That HFRS should review the tactical use of pulse spraying and its place in firefighting strategy.

Recommendation 2.15.2

That HFRS should review the training provided to personnel, particularly that given as part of the compartment fire behaviour training, to ensure it provides personnel with clear options for firefighting.

2.16 Deployment of Personnel into Hazardous Locations

Finding

The Bridgehead was established as the forward control point for committing resources to the incident. The BA Entry Control Point is situated here and firefighting teams in BA are committed through this. During the incident a number of personnel were deployed into high risk areas as lone workers.

Individuals proceeded beyond this point up to the fire floor level and above, without adequate safeguards, eg, records of their deployment location, BA and communications equipment. The deployment of lone workers into hazardous environments is of particular concern.

Evidence source: HFRS witness statements.

Recommendation 2.16.1

That ICs should be reminded of the dangers of lone workers and other personnel being committed without adequate safeguards into hazardous areas.

2.17 Marking of Flats Finding

Following a previous fire, individual flats were marked to denote their number and whether the flat was an up flat or down flat. The position of the markers was at the top right hand of the flat door. During this incident, and as a result of heavy smoke logging, the signs were totally obscured rendering them ineffective.

Evidence source: HFRS witness statements.

Recommendation 2.17.1

That HFRS should consider the locations of such markings and, in liaison with the Local Authority, consider their relocation nearer to the ground level.

2.18 Maintenance of Fire Resisting Structures around Flats

Finding

During firefighting operations, crews were instructed to locate, and force open if necessary, the fire escape door to Flat 72. Incorrect intelligence led them to force open several front doors in their attempts to locate the correct door. These operations were carried out during the incident and at a time when the residents had been instructed to stay in their flats as part of the ‘stay put policy’. Forcing the doors to the flats compromised the fire resisting construction provided by the doors and led to smoke and gases entering several flats. Had residents still been present within these flats their safety may have been compromised.

Evidence source: HFRS witness statements.

Recommendation 2.18.1

That all personnel should be reminded of the need to maintain the integrity of the fire resisting construction surrounding individual flats. Where a need develops that requires a forced entry to a particular flat, great care must be exercised to ensure it is the correct flat/door before breaking in.

2.19 Use of Positive Pressure Ventilation during Firefighting Operations

Finding

During the escalation of the incident the use of PPV was initiated in an attempt to secure escape routes for personnel and occupants in the building above the ninth floor. PPV was subsequently established within the eleventh floor corridor giving access to Flat 72 escape door. Issues arising from this action include:

  • No clear plan of action was established and communicated to the Command Team and other personnel likely to be affected by PPV operations.
  • No dedicated command structure was established to manage PPV operations.
  • PPV was established without the creation of adequate ventilation ports, effectively pressurising the eleventh floor corridor and flats accessing that corridor. A number of the flats had their front doors broken into by firefighters allowing the ingress of smoke into the flats.
  • Use of PPV before the fire was extinguished (in ‘offensive’ mode) or effectively controlled resulted in ‘offensive’ use, although this was not the planned scenario.
  • An operating PPV fan was moved into the eleventh floor corridor without notifying teams working within, worsening conditions and severely restricting communications.

Evidence source: HFRS witness statements.

Recommendation 2.19.1

That HFRS review its use of PPV in an ‘offensive’ mode and reinforce the agreed policy.

3 Communications

3.1 Acquisition of Information from 999 Callers

Finding

Fire Control Training Notes state that the task of the Control Operator is to: “Gather information from the caller to determine the nature and exact location of the incident”. It is important that this is done as quickly as possible, while at the same time ensuring that sufficient information is gathered to enable crews to locate the incident.

The first 999 caller to HFRS reporting the fire at Shirley Towers informed Fire Control of the correct flat number, the floor the flat was situated upon and that he could see flames in the lounge. This initial call was taken by a Control Operator and monitored by the Supervisor.

Critical elements of this initial call were not passed to the attending IC/other appliances, specifically, no mention was made of the floor or where the fire had been seen.

Fire Control did not ask the caller any supplementary questions such as whether there were any persons known to be in the flat. Despite several communications with Control, including an early make up, the information passed to Control from this initial 999 call was not passed on to the IC.

Control remained confused regarding the Fire Floor throughout the incident, and this became an issue every time information was requested by attending or mobilised officers.

Evidence source: HFRS control tape and HFRS witness statements.

Recommendation 3.1.1

That it is vital that all pertinent information regarding the incident elicited from the caller(s) should be recorded as a Control ‘information asset’ and arrangements put in place to ensure information is shared between Control Operators and updated as more information becomes known. Consideration could be given to the provision of a large display screen in Control (perhaps twinned in the Command Suite) for display of information relating to large scale incidents.

Recommendation 3.1.2

That all pertinent information relating to the incident should be passed to the IC at the earliest opportunity.

Recommendation 3.1.3

That Fire Control should review their procedures for obtaining important information from 999 callers. Consideration should be given to providing a (electronic) checklist for Control Operators as an aide-memoire to the information they should seek from callers.

Recommendation 3.1.4

That call handling is recognised as a key skill for Fire Control and should be incorporated in regular training and assessment.

3.2 Provision of Fire Survival Advice

Finding

Fire Control will provide callers with fire survival advice where they feel the caller is in a hazardous situation and requires advice on how best to safeguard themselves whilst they await the arrival of HFRS. The Control tapes indicate that five members of the public were provided with such advice, one call lasting in excess of one hour and 20 minutes. This individual was on the fifteenth floor (with the fire not spreading vertically) and the tape suggests that this person was not in danger or distress. At the time this protracted conversation was being conducted Fire Control were experiencing very high work loads and having to recall staff to assist.

Fire Control Operators are provided with a standard procedure for providing survival advice for flats in blocks over four floors. This advice is very generic and some of the advice given by the operators was not suitable for the design of Shirley Towers. An informed knowledge of the building would have enabled more precise advice to have been given. The current procedure for Control suggests that the calls can be terminated after an explanation to the caller if the volume of calls being received requires this.

Evidence source: HFRS control tape.

Recommendation 3.2.1

That Service Delivery should examine the guidance on fire survival advice and ascertain if a generic guidance document is applicable to the scissor type flats.

Recommendation 3.2.2

That Service Delivery should review the criteria for providing fire survival advice and, where the caller is not in danger, consideration should be given to closing down the call.

3.3 Rescue of Persons Receiving Fire Survival Advice

Finding

Shirley Towers has a ‘stay put policy’ for residents in the event of a fire. This policy is utilised where previous risk assessment has decided that residents would be safer staying in their flat than attempting escape. Adoption of this policy meant that there were potentially significant numbers of people in the flats. The occupants of five flats (situated on floors 9, 11 and 15) received fire survival advice and throughout the period in which advice was being given the residents were repeatedly told that the fire and rescue service was on its way. Several residents sounded very distressed and in need of urgent assistance. Despite the apparent urgency of reaching these residents, no specific rescue plan was undertaken until some time into the incident. On several occasions Fire Control contacted the various Contact Points to suggest physical contact with the most vulnerable residents but recordings suggest these had an unsatisfactory outcome.

Evidence source: HFRS control tape.

Recommendation 3.3.1

The IC, where Fire Control are in contact with concerned residents, should liaise closely with Control to assess the level of risk to individual residents. Where Control feel that the risk is significant, eg, from fire spread or smoke percolation, they should inform the IC who can develop a strategy to ensure early rescue is undertaken.

3.4 Use of Mobile Telephones at Incidents

Finding

Mobile telephone records covering the incident show that significant communications and key messages between officers and Fire Control were made with the use of mobile telephones. Custom and practice has meant that mobile telephones have become the communication of choice for some officers. Communication by mobile telephone:

  • Largely prevents the recording of the content as would be the case if communications were made via the Incident Support Unit(s). This can lead to the loss of information.
  • Is personally focussed and the information not shared with other personnel.
  • May lead to sensitive personal data being passed to non HFRS personnel. This has the potential for victims’ families hearing details of their loss from an unofficial source.

Evidence source: HFRS mobile telephone records, HFRS witness statements and fire control tape.

Recommendation 3.4.1

That the use of mobile telephones for important operational communications should be discouraged (other than in exceptional circumstances such as where other communication systems have failed or there is an overriding need for confidentiality).

Recommendation 3.4.2

That all personnel should be reminded of the importance of not passing sensitive personal information to friends and family from the fire ground.

3.5 BA Set Data Readings

Finding

The Bodyguard device fitted to the BA sets was commonly understood to measure temperature, air consumption, cylinder contents and operation of the ADSU. Detailed review of the data downloaded from the device was often prevented because of an inherent software failure that provided corrupted data. Other noted shortcomings include, for example, temperature readings that bear little practical relationship to ambient temperatures, and any operation of the ADSU prevents the collection of any further data.

Evidence source: Draeger BA set data record.

Recommendation 3.5.1

That HFRS consider what physiological information they require to be collected for BA wearers and then to assess if the current equipment is capable of providing this type of data and in sufficient detail and accuracy.

3.6 Silencing of Fire Alarm

Finding

The fire alarm in Flat 72 operated on detection of the fire and was not silenced for several hours. These alarms emit a very loud audible alarm that can mask the operation of ADSUs, disrupt conversations and interfere with radio messages. In addition the noise can confuse or disorientate personnel and the public.

Evidence source: HFRS witness statements.

Recommendation 3.6.1

That the IC should ensure that such alarms are silenced as soon as practicable after arrival and after residents have been warned of the incident.

3.7 Informative Messages

Finding

The early transmission of an informative message is vital for senior officers not in attendance at the incident to gauge the need for deploying additional resources. The first informative message from this incident was sent at 20:51 (37 minutes after the arrival of the first appliance), this after repeated prompts from Fire Control.

Evidence source: HFRS control tape.

Recommendation 3.7.1

That ICs should be reminded of HFRS policy regarding the need to ensure that a comprehensive informative message is sent at the earliest practical time. Fire Control should review their practice for messaging prompts.

3.8 Verification of Fire Ground Information from ‘Non Control Point Sources'

Finding

Control tapes show that significant pieces of information were passed from non fire ground Control Point sources to Fire Control, for example, at 21:12 notification of the BA emergency was apparently initiated by Command 2 (this whilst 54 Echo Uniform was still the Contact Point) and not from the IC. The danger of routing information in this way is that the information may not have originated from the IC who may be unaware of a significant piece of information. Similarly the fire ground Control Point may also be oblivious to what information has been passed.

Fire Control staff have confirmed that there is no current procedure for checking fire ground information from non Control sources.

Evidence source: HFRS control tape.

Recommendation 3.8.1

That all personnel should be reminded of HFRS policy stating that communication from the fire ground to Fire Control must be via the agreed fire ground Control Point on scene.

Recommendation 3.8.2

That HFRS should implement a procedure within Fire Control to ensure any fire ground information received from sources other than the IC is validated as soon as possible.

3.9 Inappropriate Communication Procedures

Finding

The Control tapes indicate that some communications with Fire Control were inappropriate, eg, officers not yet mobilised to the incident contacting Control for details. The form of address between callers and Control was less than formal with the standard greeting generally “hello mate”. This familiarity was also evident in personal radio communications. The use of first names was widespread which can lead to some confusion.

Evidence source: HFRS control tape.

Recommendation 3.9.1

That, in accordance with HFRS policy, personnel using radio communications should use the correct terminology, including the correct term of personal address, for example “From Group Manager Dollery…”

Recommendation 3.9.2

That the correct use of radios and standard terminology should be practised during training.

3.10 Hand Held Radios Finding

The hand held radios used by HFRS may not always operate effectively in high rise buildings. These radios are also used by BA wearers to communicate with the BAECO. At this incident communications proved difficult necessitating the need to use other forms of communications, notably mobile telephones. The problem of poor radio communication in structures such as high rise buildings or ships is well known. Post incident testing of radios by HC showed that they were operating effectively. There were instances throughout the incident of some key personnel not having radios, eg, the second BAECO.

Evidence source: HFRS witness statements.

Recommendation 3.10.1

That HFRS should review the effectiveness of its hand held radios and how any loss of communications should be a factor when considering the declaration of a BA emergency.

4 Breathing Apparatus Procedures

4.1 Availability of Breathing Apparatus Control Board

Finding

HC video shows a number of BA board entries marked on the wall of the seventh floor. These entries were made as a result of insufficient BA control boards being available at the point of entry and the need to commit additional BA crews.

Evidence source: HC video and HFRS witness statements.

Recommendation 4.1.1

That personnel be reminded of the need to take sufficient BA control boards to the point(s) of entry. The newly issued High Rise Service Order 7/4/1 stipulates this. This should be emphasised during training.

4.2 Overwriting of Breathing Apparatus Control Board

Finding

Seizure of the BA control board for the initial crews deployed reveals that the BA tally information was not overwritten on the board by the BAECO. Overwriting the tally details is deemed good practice to ensure accurate records can be maintained even if individual tallies become temporarily dislodged from the board.

Evidence source: HFRS witness statements, HC photographs and exhibit.

Recommendation 4.2.1

That personnel be reminded of the need to overwrite tally details on BA boards whilst crews are committed into incidents. Supervisory Officers should monitor BAECOs to ensure this practice is adhered to.

4.3 Instigation of Stage 2 Procedure

Finding

Service Order 7/4/1 which covers High Rise Incidents states that Stage 2 BA control procedures should be introduced as soon as resources allow. This stage of BA control introduces a number of measures necessary for a large incident. These measures include for example, the role/level of the BAECO and the provision of an emergency crew.

Despite the policy outlined above, the complexity of the incident and the large number of breathing apparatus wearers deployed, Stage 2 BA control was not implemented.

Evidence source: HFRS witness statements.

Recommendation 4.3.1

That ICs be reminded of the need to instigate BA control Stage 2 procedures as soon as practicable at incidents as designated in HFRS Service Order 7/7 Breathing Apparatus (Para 1.5.2). Training exercises should be conducted to practice this procedure to ensure it is fully embedded.

4.4 Initiation of a BA Emergency

Finding

Service Order 7/4/1 High Rise Buildings, requires that the Bridgehead be located at least two clear floors below the incident floor. The BAECO will normally be sited at the Bridgehead and instigate a BA emergency if any of the following criteria apply:

  • BA wearers fail to appear before time of whistle.
  • Operation of an ADSU by BA wearer.
  • Any exceptional circumstances that suggest to the BAECO that the BA wearers may be in difficulty, eg, building collapse.

Ff Bannon’s time of whistle was 21:06 and Ff Shears’ time of whistle was 21:01. In calculating the time of whistle (the team exit time) the BAECO would default to the earliest time for both wearers (21:01).

The manual operation of Ff Shears’ ADSU at 20:52 and Ff Bannon’s operating automatically (on the detection of no movement) at 21:00, was not heard by either the BAECO or any other personnel on the Bridgehead several floors below. Despite the time of whistle calculations suggesting a crew return time of 21:01 the BA emergency was not declared to Fire Control until 21:08.

Whilst the loss of personal radio communications is not in itself a trigger for instigating a BA emergency, the loss of communications should act as an indication that the BA team may be in difficulty. Personal radio communications are known to be difficult in high rise buildings and, because of this, any loss of communication may not have automatically led to an increase in concern for the safety of the BA team.

Evidence source: HFRS witness statements, Southampton CCTV, HFRS Control and Command 1 tapes.

Recommendation 4.4.1

That personnel be reminded of the HFRS policy for initiating a BA emergency, in particular the time of whistle calculation time. Such scenarios should be incorporated in routine training exercises. Supervisory Officers should monitor these arrangements to ensure strict adherence.

Recommendation 4.4.2

That the Service consider the introduction of suitable telemetry to ensure that any operation of an ADSU is immediately relayed to the BAECO regardless of location.

4.5 Use of Breathing Apparatus Wearers

Finding

During this incident, CCTV showed that several personnel made more than one entry wearing BA after a significant climb up from the Bridgehead several floors below. The entry control records show that the rest period between deployments was often less than 15 minutes.

A recent three year research project, funded by the Fire and Rescue Service Research Training Trust, and contained in Fire Research Technical Report 18/20081, suggests that with rest periods of less than 15 minutes between deployments, firefighters are unable to recover fully and consequently experience a greater level of physiological strain during subsequent firefighting activities. Heat stress can reduce performance on working memory tasks and reaction time. The ability to make correct decisions can also be reduced.

Rehydration was also noted to be important in lowering body temperatures and replacing fluid loss from sweating.

Evidence source: Southampton CCTV and HFRS witness statements.

Recommendation 4.5.1

That personnel committed to wear BA are provided with sufficient time to fully recuperate between deployments. The nature and location of the incident will be a factor in deciding this, for example, at a high rise incident where personnel are required to walk up several flights of stairs carrying equipment or dragging hose, the recuperation period will be longer.

Recommendation 4.5.2

That consideration be given to the introduction of a specialist response vehicle to support the recovery of personnel and reduce their body temperatures and consequential stress levels. For firefighting, search and rescue activities conducted under conditions of live fire and continued to the operation of the low cylinder pressure warning whistle, the average firefighter should have at least 50 minutes of recovery, ideally, but not necessarily in a cool environment, with their PPE removed, and to consume a minimum of 1000ml of cold water. This recovery duration should be extended to at least 65 minutes to protect 95% of firefighters engaged in more typical 20 minutes deployments and redeployments.

Recommendation 4.5.3

That the current method of rehydrating firefighters at incidents with bottled water should be reviewed to assess the option of providing isotonic sports drinks and rehydration powders.

4.6 Fluctuations in Air Consumption by Breathing Apparatus Wearers

Finding

The current method of calculating the duration of a BA set is by dividing the contents (in litres) by 40. This calculation gives the total duration in minutes of the cylinder, from this is deducted the safety margin of 10 minutes which in turn provides the working duration.

This calculation is based on a nominal consumption of 40 litres a minute and takes no account of an individual’s physical fitness (as a general rule, a physically fit individual will consume less air than someone larger or less fit) or the arduous nature of the work undertaken.

In recognition of this potential fluctuation in consumption BAECOs are reminded by the BA control board which clearly states that ‘hard work will reduce duration’.

Where a BA crew is being committed the lowest cylinder pressure is used to calculate the time that all members of the crew should retire to the BAECO.

The only method for a BAECO to update their calculations is for BA crews to regularly take gauge readings and to relay these to the BAECO – there is no provision in the current Service Order 7/7 recommending this practice.

Whilst there is no suggestion that initial duration calculations should be amended, any additional air consumption information relayed from the crews to the BAECO can only assist in improving the understanding of the BAECO (and through him/her the IC) about the conditions being experienced by the crews, for example, an indication of excessive consumption might prompt early deployment of an emergency or relief crew whereas information that consumption was less than that projected might allay fears if a crew were a few minutes over their departure time from the incident.

Evidence source: HFRS witness statements.

Recommendation 4.6.1

That HFRS consider amending its BA Service Order and teaching to include the practice of BA wearers relaying gauge readings back to the BAECO on a regular basis.

4.7 Effectiveness of Automatic Distress Signal Units

Finding

ADSUs are a component of the Bodyguard apparatus fitted to HFRS BA sets. They are designed to provide an audible alarm and are rated at between 102 and 112 decibels measured at 250mm. Because of the location of the alarm on the shoulder strap it is possible that a BA wearer in distress may lie on the ADSU and muffle the alarm. The alarm provides no directional guidance to rescue crews. The sound emitted is similar to that made by other alarms, eg, smoke detectors, freezer warning, etc, and can therefore be confusing to crews.

Because of the distance between the crews and the Bridgehead, the alarm would not have been audible to them and the alarm would not have been raised. Only other crews working in the same proximity would have been able to hear the alarm.

Evidence source: HFRS witness statements.

Recommendation 4.7.1

That HFRS research other methods of signalling BA wearer distress. The opportunity should be taken to examine methods of providing the BAECO, and rescue teams, with directional information to speed the rescue process.

4.8 Briefing and Debriefing of BA Crews

Finding

Red Team 1 were committed to the incident without a full and comprehensive brief as to what actions they were to undertake, the team themselves deciding that they would undertake a right hand search. This was not done in the presence of the BAECO. The brief for Red Team 2 was also less than comprehensive and also not conducted in the presence of the BAECO. This resulted in the BAECO not having a clear and concise understanding of where crews were being deployed and their allotted tasks. Service Order 7/7 Para 1.3.3 (which is based on Home Office Technical Bulletin 1/1997) requires the Incident Commander to ensure that effective briefing and debriefing takes place. Para 1.4.5 states that it is the responsibility of the BAECO where practicable to ensure BA wearers are briefed prior to entry to the risk.

This became more important when Red Team 2 were reported missing and little precise information was known about their whereabouts. When Red Team 1 reported back to the BAECO they did so in a blackened condition with burnt hands and in a distressed state. Their appearance coincided with rising concern over the whereabouts and safety of Red Team 2. Despite these ‘unusual circumstances’ no one sought to either debrief them or seek information on Red Team 2.

Evidence source: HFRS witness statements.

Recommendation 4.8.1

That, in accordance with HFRS policy, the IC, sector officers and BAECOs must ensure a comprehensive brief regarding the strategy for adoption is provided to all crews before they enter an incident. The briefing should be in the presence of the BAECO who can record pertinent details on the BA entry control board.

Recommendation 4.8.2

That, in accordance with HFRS policy, the BAECO is responsible for ensuring all teams exiting the incident are debriefed to obtain all pertinent information, for example, information relating to conditions, areas of search, etc. This information should be recorded on the BA board and, if important, passed immediately to the Sector Commander.

4.9 Communication Between BA Teams

Finding

Red Team 1 had been instructed not to enter the flat until they were joined by a further team. As soon as Red Team 1 saw the second team by the lobby door, they entered the flat. At this point the teams were only four metres apart. No communication took place between the teams. In not waiting the few seconds required for Red Team 2 to join them, Red Team 1 prevented the exchange of important information such as search strategy to be adopted and use of jets.

Evidence source: HFRS witness statements.

Recommendation 4.9.1

That personnel be reminded of the importance and benefits of effective and robust communication between crews. This should be practised during training.

4.10 Condition of BA Control Boards

Finding

Evidence examined during the investigation suggested that BA control boards in use were not in a clean state. The current boards require tallies (with chinagraph pencil writing) to be pushed into a tight ‘slot’ at the left side of the board, with the result that chinagraph residue is deposited on the inaccessible face of the BA board.

This situation is exacerbated by the use of chinagraph pencil on the board itself which means that when entries are rubbed off the board, a black residue remains that can affect the clarity when the board is next used, particularly in hours of darkness. This is particularly noticeable under the first section marked ‘identification’.

Evidence source: BA boards.

Recommendation 4.10.1

That HFRS investigates what changes to construction could avoid this contact between the completed face of the tally and the BA board. The Service should research and provide a suitable solvent that can be used to clean the board after use.

4.11 Provision of Thermal Imaging Camera for use by Emergency Team Finding

Current Service policy does not require the provision of a TIC at the Entry Control Point (ECP) for use by an emergency team. The use of a TIC at an incident where visibility is compromised will greatly assist the user in locating casualties. Evidence source: HFRS witness statements.

Recommendation 4.11.1

That the Service review its BA policy and consider the provision of a TIC at the ECP for use by an emergency crew.

4.12 Supervision and Support of the BAECO

Finding

Incidents involving the use of BA require a very high degree of supervision and control to ensure wearer safety. The responsibilities of the BAECO are numerous and complex. Standard BA control procedures state that complex incidents should have Stage 2 BA control in operation and that the BAECO should be a minimum of a Crew Manager (CM).

Evidence source: HFRS witness statements.

Recommendation 4.12.1

That Supervisory Officers monitor the performance of the BAECO and if necessary provide additional resources to support and assist him/her in carrying out their duties.

4.13 Provision of Communication Equipment for the BAECO

Finding

The second BAECO was not in possession of a personal radio when the BA board was set up. This omission meant that the second BAECO was not in contact with any of the BA crews committed through his entry point. Furthermore, as the board had been set up some distance from the first board, he was not in contact with the other BAECO. The implications of this are that the second board was working in isolation.

Evidence source: HFRS witness statements.

Recommendation 4.13.1

That personnel are reminded of the importance of having a personal radio with them when undertaking the duties of BAECO. Supervisory officers should monitor communications at the BA control entry point.

4.14 Recording of information on the BA Control Board

Finding

Photographs of the impounded BA control board (first board used) reveal that vital information relating to the incident had not been recorded on the board. Missing information includes the equipment the teams were carrying, eg, TIC, firefighting equipment, etc, the brief/tasks allotted to the team and team location. This omission means that the BAECO, and any supervisory officer, did not have access to important information.

Evidence source: HFRS witness statements, photographs of impounded BA board.

Recommendation 4.14.1

That all personnel likely to undertake the duties of a BAECO are reminded of HFRS policy regarding the importance of recording pertinent information (relating to committed BA crews) on the BA control board.

4.15 Adequacy of BA Board to Record Details of Incident

Finding

Examination of the existing issue of BA board reveals a space for recording remarks that measures 100mm wide by 45mm deep. Into this space the BAECO has to record all pertinent details regarding the team listed above. Using what is often a blunt chinagraph pencil restricts the actual information that can be recorded in the space provided.

A similar space is available to record the location of the team.

Evidence source: Examination of existing (2010) BA entry control board.

Recommendation 4.15.1

That HFRS review the current board design and consider a next generation board that incorporates more available space for the BAECO to record important information, eg, with a hinged flap which doubles the available size of the board. (AIT understand that at least one other fire and rescue service already uses a board using this design).

4.16 Relief of BA Crews Prior to their Time of Whistle

Finding

A number of BA crews engaged on firefighting operations reached the time at which they should have withdrawn from the incident before relief crews had arrived to replace them. In at least one case, a crew engaged on firefighting remained well into their time of whistle because no-one had arrived to replace them. They felt that had they retired, as procedures dictate, the fire would have developed in an uncontrolled manner so endangering the missing crew.

Evidence source: HFRS witness statements.

Recommendation 4.16.1

That, in accordance with HFRS policy, BAECOs maintain communications with BA crews and monitor their air consumption. They must ensure BA teams are relieved at the scene of operations in sufficient time to allow their return to the ECP prior to their ‘time of whistle’. Ultimate responsibility for ensuring a safe system of work rests with the IC.

Recommendation 4.16.2

That BA crews are reminded of HFRS policy regarding the necessity of withdrawing from the scene of operations and returning to the ECP before their low pressure warning whistle operates.

5 Training and Competence

5.1 Personnel Training Records

Finding

Review of individual training records showed that some personnel were recorded as having undertaken/received considerable amounts of training, on a wide range of subjects, on a single shift.

Evidence source: Personnel training records.

Recommendation 5.1.1

That the Training Department review the procedures for:

  • The recording of training activities.
  • The process for checking and validation of training records by supervisory officers.

5.2 Interpretation of Information as Part of the Dynamic Risk Assessment Process

Finding

Some personnel entering Shirley Towers risk areas were presented with several significant indicators as to the risk. The evidence reviewed by the AIT identified that it appears that the term ‘Dynamic Risk Assessment’ (DRA) is sometimes utilised without acknowleding the relevance of the DRA process and its practical application.

Evidence source: HFRS witness statements.

Recommendation 5.2.1

That HFRS review the use, understanding and application of DRAs operationally within the Service. Effective use of DRAs should be practised during training and their usage on the incident ground monitored by supervisory officers.

Incident Command and Control

6.1 Functional Command Communications

Finding

The Command tapes indicate that there were numerous occasions when the Command Support Officers (CSO) were unable to locate command officers at the incident. CCTV shows officers moving in and out of the building and on differing floors. Some officers chose not to have a personal radio which made contact extremely difficult. The CSO had to make several radio requests to gain access to some officers.

Evidence source: Southampton CCTV and HFRS Command 1 tape.

Recommendation 6.1.1

That officers ensure they have a personal issue radio when on the fire ground; reliance on accompanying personnel with radios can cause communication difficulty if the parties become separated.

Recommendation 6.1.2

That officers at incidents should ensure the Control Point knows their location at all times. Wherever possible the IC should remain at the Control Point.

6.2 Incident Command Qualifications

Finding

The initial Bridgehead Commander was not trained or assessed in incident command level 1. The first and second ICs had received training and previous assessment at level 1 and 3 competence respectively but at the time of the incident their qualifications had lapsed pending further assessment.

Evidence source: HFRS training records.

Recommendation 6.2.1

That HFRS conduct a review of the status of officer incident command competence and the currency of their qualifications.

Recommendation 6.2.2

That HFRS conducts urgent training and assessment of any unqualified officer to the appropriate level of incident command competence.

Recommendation 6.2.3

That HFRS reviews its procedures for ensuring all personnel required to take command of an incident, are trained and assessed to maintain competence and qualification.

6.3 Accurate Record of Contact Point and Current Officer in Charge

Finding

As incidents escalate, the level of control and IC will change. This incident resulted in the Control Point initially being set up in Redbridge’s WL before transferring to the SEU then moving to Command 2 and then finally to Command 1. These transfers of Command Point were not always notified to either Fire Control or supervisory officers on the fire ground. This caused some confusion and subsequent delays in the passing of information.

The transfer between the SEU to Command 2 and then Command 1 took place within 12 minutes at a critical time during the incident. Similarly, as the IC changed, Fire Control were not always informed of the change of command. Command tapes suggest that, on occasions, the on scene Control Point were not aware of who the current IC was.

Evidence source: HFRS control tape and Command 1 and 2 tapes.

Recommendation 6.3.1

That, in accordance with HFRS policy, the IC ensures any alteration to the on-scene Command Point is notified to Fire Control as soon as it is in operation. Responsibility for this communication can be delegated to the CSO. Fire Control must ensure that all Control staff receive this information at the same time to avoid the possibility of individual Fire Control operatives attempting to communicate with different Control Points.

Recommendation 6.3.2

That, in accordance with HFRS policy, ICs ensure that, as they take over command of the incident, this is notified to Fire Control, the on-scene Command Point and all functional officers at the scene.

Recommendation 6.3.3

That HFRS review the Command vehicle mobilisation policy so that the Command 1 vehicle is sent to known escalating incidents rather than the (current) practice of always mobilising Command 2. Such a change would reduce the handover process between command vehicles and the potential for errors, omissions or delays such handovers may cause.

6.4 Briefing of Officers and Appliances En Route to Incident

Finding

Fire Control are required to pass all relevant information to officers and appliances en route to incidents, to assist in the officers’ pre-planning process. Historically, officers had radios fitted to their cars which allowed them to receive messages from Fire Control and monitor radio traffic between Fire Control and the fire ground. The recent removal of these radios from officers cars has made the passing of information to responding officers difficult. Control tapes show that, despite requests for information from officers en route to, and those in attendance at, the incident important information was not passed to them.

Officers sent on relief duties were not informed of the firefighter fatalities prior to their arrival at the incident. This omission had the potential for an embarrassing or distressing situation.

Evidence source: HFRS control tape and email from Service Delivery 26 January 2011.

Recommendation 6.4.1

That Service Delivery/Fire Control review their methodology for passing information to officers and appliances en route to incidents. This includes forewarning them of any sensitive issues ahead of their arrival at the incident. As part of this review it is further recommended that a system be introduced within Fire Control to ensure that identical and current information is passed to all recipients.

6.5 Booking Mobile To and In Attendance at Incidents

Finding

Effective command and control of incidents requires that the location of resources (appliances and officers) is accurately recorded at Fire Control and the on-scene Command Point. A number of officers do not appear to have booked mobile to, or in attendance at, the incident.

Evidence source: Fire Control tape and Command 1 and 2 tapes.

Recommendation 6.5.1

That officers are reminded of the importance of accurately informing Fire Control (or the on-scene Command Point) about their movements or location.

Recommendation 6.5.2

That Fire Control review their procedures for monitoring the movement and location of resources.

6.6 Transfer of Information Between On Scene Command Points

Finding

Fire Control tapes show that some important information was not transferred between Command Points as the incident escalated. There are procedures in place governing such transfers.

Evidence source: Fire Control tape and Command 1 and 2 tapes.

Recommendation 6.6.1

That personnel are reminded of HFRS policy regarding the importance of transferring information between Command Vehicles as the incident escalates and Command Point changes.

6.7 Recording of Information in the Control Log

Finding

The names of the two firefighters conveyed to hospital (and subsequently pronounced deceased) were passed to Control but a decision was taken not to enter this in the Control Log. This information could not then be retrieved and this had the effect of having to duplicate the casualty identification process and so delay the time at which the families could be informed.

Evidence source: HFRS witness statements.

Recommendation 6.7.1

The Incident Control Log is a secure document and is used to record all important details of incidents. It is recommended that Control staff are reminded of the need to use this format to record all important details including those of any casualties.

6.8 Implementation of Search Sector Finding

ICS guidance states that more than one internal sector may be required to ensure that the Sector Commander’s spans of control are not exceeded. During this incident the Bridgehead Sector Commander was primarily responsible for firefighting but undertook additional responsibility for the rescue and evacuation of residents remaining in Shirley Towers and forced ventilation of the escape corridors.  

In these circumstances it may have been beneficial to establish a dedicated Search Sector to deal with the control of other issues.

Evidence source: HFRS witness statements and ICS Guidance Manual.

Recommendation 6.8.1

That HFRS review its ICS policy and guidance to ensure there is specific reference to the implementation and resourcing of a Search Sector.

7 Mobilising Procedure

7.1 Pre-determined First Attendance

Finding

On 14 December 2009 Service Delivery Bulletin 70/09, was issued which increased the PDA (this term means the agreed level of resource attendance that is sent to a first call to a particular premise) to high rise premises. The PDA to Shirley Towers was increased from three fire appliances, plus a SEU, an aerial appliance and one officer to five fire appliances plus a SEU, an aerial appliance and two officers. Notification of this upgraded PDA was circulated to all personnel prior to its introduction.

When the IC made Pumps 6 (in effect one additional fire appliance) he stated that he did so in recognition that the PDA had recently been changed and that as this was his first high rise incident following that change, he wanted to ensure that Control sent the required number of appliances.

Evidence source: HFRS witness statement, Service Delivery Bulletin 70/09 and Fire Control tape.

Recommendation 7.1.1

That HFRS review its methodology for ensuring its staff are in receipt of the most up to date information with regard to mobilising standards.

8 Organisational Policy and Procedures

8.1 Health and Safety Near Miss Reports

Finding

Service Order 8/2/1 Injuries, Near Miss, Dangerous Occurrences and Occupational Diseases (Safety Events) states that a Near Miss Report FM/8/2/1 is to be completed and submitted in respect of a near miss. These reports are used to identify issues and any potential shortcomings in procedures, equipment or PPE. Unfortunately the near miss reporting procedure is not being used as comprehensively as it should, resulting in serious and potentially critical learning points not being reported and therefore not acted upon to reduce the likelihood of a reoccurrence. Despite as many as six personnel ‘mentioning’ that fallen cables had been an issue for them, only two near miss reports were submitted, and these only after prompts by the FBU.

Evidence source: HFRS Health and Safety Adviser.

Recommendation 8.1.1

That HFRS review its guidance on when and how near miss reports are to be submitted and ensure all personnel, especially officers in charge, are aware of the importance of submitting these reports. Supervisory Officers should ensure where there are any near miss occurrences, that a comprehensive report on what happened is submitted.

8.2 Service Orders

Finding

As part of the investigation process the currency of Service Orders was checked to assess their accuracy. The current listing for the revision of Service Orders suggests that a significant number of them are beyond their revision date. The AIT are not confident that this listing is accurate.

Evidence source: Service Order revision programme held by Central Services.

Recommendation 8.2.1

That the revision dates for all Service Orders are reviewed and prioritised for urgent review and revision.

Recommendation 8.2.2

It is further recommended that individual Service Orders are allocated to a post within the holding directorate, for example Service Delivery: Area Manager (Response). This post holder to become responsible for ongoing review and revision of the specific Service Orders allocated to their post.

8.3 Debrief Reports

Finding

During the investigation there was concern that some important issues raised by the Shirley Towers incident had been encountered at previous incidents and not fully addressed as part of the original debrief process. This is not a suggestion that debriefs are not held, indeed there is strong evidence that they are.

Evidence source: HFRS incident debrief reports.

Recommendation 8.3.1

That the current methodology for conducting incident debriefs should be reviewed to ensure that all pertinent findings from the debrief are robustly addressed and any remedial actions taken are fully auditable.

8.4 Archiving of Reports into Significant Incidents

Finding

During the course of this investigation the AIT team encountered difficulty in obtaining copies of previous reports into significant incidents.

Recommendation 8.4.1

That HFRS review its policy and procedures for archiving significant incident reports.

--end--

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

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

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

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

IFE Commentary & lessons if applicable

None produced at this time.

Known available source documents

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

FRS Incident Report/s

Hampshire Fire and Rescue Service (HFRS). (Unknown date). Report of the Hampshire Fire and Rescue Service investigation into the deaths of Firefighters Alan Bannon and James Shears in Flat 72, Shirley Towers, Church Street, Southampton, SO15 5PE, on Tuesday 6 April 2010. [pdf]  Available at Shirley Towers - Final REDACTED FRS. HFRS.

FBU Incident Report/s

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

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

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

Hampshire Constabulary Incident Report/s

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

South Central Ambulance Service Incident Report

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

Building Research Establishment (BRE) Reports/investigations/research

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

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

Shropshire and Wrekin Fire and Rescue Authority. (unknown date). Coroner’s Rule 43 Letter Shirley Towers, Hampshire. [pdf]. Available at https://www.shropshirefire.gov.uk/sites/default/files/fra/11-coroners-rule-43-letter.pdf [Accessed 9th April 2017].

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

Other information sources

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

Service learning material

Hampshire Fire and Rescue Service (HFRS). (unknown date). Shirley Towers interim learning package. [DVD]. HFRS.

 Photo 13

Hampshire Fire and Rescue Service (HFRS). (unknown date). Shirley Towers interim learning package; interim FRS presentation (Redacted). [PowerPoint]. HFRS.

Hampshire Fire and Rescue Service (HFRS). (unknown date). Shirley Towers interim learning package; presenters brief. [PDF]. HFRS.

Hampshire Fire and Rescue Service (HFRS). (unknown date). Shirley Towers fatal fire; organisational response and key learning points. [DVD]. HFRS.

Photo 14

Videos available

Please see above section for more video information.

YouTube. (2013). Shirley Towers report part 1. [online] [Accessed on 28th July 2016].

YouTube. (2013). Shirley Towers report part 2. [online] [Accessed on 28th July 2016].

Go back