The Fire Brigades Union

Fatal AccidentInvestigation– Summary Report

Into the deaths of firefightersIan Reid, John Averis, Ashley Stephensand Darren Yates-Badley

At

Wealmoor (Atherstone) Ltd,Atherstone on Stour,Warwickshire

Friday 2 November 2007

2

Contents

1) Introduction – Matt Wrack, FBU general secretary...............................................................3

2) Synopsis .................................................................................................................................................................................4

3) Sequence of events...................................................................................................................................................5

4) Evidence collection...............................................................................................................................................14

5) Analysis ...............................................................................................................................................................................155.1 What happened? .........................................................................................................................................155.2 How did it happen?.................................................................................................................................155.3 Why did it happen? ..................................................................................................................................15

6) Conclusions....................................................................................................................................................................216.1 Specific conclusions...............................................................................................................................216.2 General conclusions...............................................................................................................................22

7) Recommendations..................................................................................................................................................247.1 IRMP ..........................................................................................................................................................................247.2 Incident command ...................................................................................................................................247.3 Breathing Apparatus...............................................................................................................................25

3

1) IntroductionMatt Wrack, FBU general secretary

Firefighters Ian Reid, John Averis, Ashley Stephens and Darren Yates-Badley died at a firein Atherstone on Stour, Warwickshire on 2 November 2007, the worst incident of multiplefirefighter fatalities in the UK since the 1970s.

The tragic deaths of these four firefighters in Warwickshire – together with other deathsin Strathclyde, North Wales, Hertfordshire, and Dumfries and Galloway – made 2007 anunprecedented year for firefighter deaths in recent times. Eight firefighters died on dutyin 2007 alone, the worst year since 1985.

Since then firefighters have died at operational incidents in Central Scotland in 2008,Lothian and Borders in 2009, Hampshire in 2010 and Greater Manchester in 2013. Thetrend in firefighter deaths was downwards until the turn of the century. From 1997 until2002 there was not a single recorded firefighter death at a fire anywhere in the UK.

However there has been an alarming upturn in recent years. Firefighter deaths at fires rose sharply in the years2003-2007, and there have been further deaths since. This suggests that lessons are still not being learned.Alarmingly, it appears that there are factors which contribute to such tragedies but which are being repeated atsubsequent incidents.

This is the summary report of the Fire Brigades Union’s investigation into the incident that occurred at Atherstoneon Stour, Warwickshire on 2 November 2007.

The purpose of the FBU investigation was to establish the causes of the death of the four firefighters by analysingthe strategic planning of Warwickshire Fire and Rescue Service prior to the incident and the operations andtechniques used during the incident.

The FBU has a duty, as the union which represents firefighters throughout the UK, to investigate the causes (director underlying) behind any such incident in order to learn from it and attempt to prevent any reoccurrences.Firefighter safety and the ‘safe firefighter’ concept are at the core of the FBU’s thinking and have been generallywelcomed and accepted by the wider fire sector and politicians alike.

This summary report consists of key extracts taken from the FBU’s serious accident investigation (SAI) into theWarwickshire incident. The FBU has produced a very detailed full report, outlining the sequence of events,evidence collection, analysis and conclusions.

We want ministers in all four governments in the UK, as well as chief fire officers, fire authority members and otherpoliticians, to focus on learning the lessons from the Warwickshire deaths. The FBU wants those key decisionmakers to take action on our recommendations, to ensure that the events are never repeated.

FBU officials will be seeking meetings with key stakeholders to discuss our report and what can be done toimprove firefighter safety. Our members do not go to work to die. Firefighters assess the risks and take carefullyplanned action to rescue people, to deal with the various incidents we face and to make communities safe. Wehave the right to demand the best possible procedures, training, equipment and resources to enable us to do ourjob safely, effectively and professionally. That should not be too much to ask.

I would like to thank the FBU’s accident investigation team, Peter Goulden, Marcus Giles and Steve Laugher fortheir conscientious work, as well as FBU executive council’s health and safety specialists for their input. I am alsograteful for the support and solidarity shown by FBU members in Warwickshire and across the UK, and thank allthose FBU officials who have contributed to the investigation process.

Matt WrackGeneral secretary

4

2) Synopsis

Date:

2 November 2007.

Time:

The sequence of events covers actions and events– including the mobilising and the incident operations– that occurred between 17:36 when the first call wasreceived by mobile phone from an employee ofWealmoor to Gloucestershire Fire and Rescue Service,until approximately 21:10 when the last breathingapparatus (BA) team withdrew.

Location:

The incident was at Wealmoor (Atherstone) Ltd,Hangars 1 and 2, Atherstone Industrial Estate, A3400Shipston Road, Atherstone on Stour, Warwickshire. Thearea of the property involved in the fire consisted ofground and first floors of sandwich panel construction.It was used as a vegetable packing warehouse withapproximately 135 employees (95 production staff and40 office staff).

The nearest fire station to Atherstone on Stour is 4.2miles by road at Stratford upon Avon. Property fireswithin Warwickshire Fire and Rescue Service area havea predetermined attendance of two pumpingappliances unless previously identified as a special riskor persons reported. This had neither, so two pumpingappliances were mobilised.

Warwickshire Fire and Rescue Service is predominantlya rural brigade with 19 stations, four of which arewholetime shift stations, three day crewing stationsand 12 retained stations. Stratford upon Avon has onewholetime appliance, one retained appliance and onehigh volume pump unit.

Incident type:

Crews were attending Incident No 32952, a fire in alarge commercial property in the storage/packing areaon the first floor.

Safety event:

A team of four breathing apparatus (BA) wearers, forreasons unknown, got into difficulties within the firecompartment (storage/packing area) raising a BAemergency.

Deceased:

Watch manager Ian Reid Age 44 yearsFirefighter John Averis Age 27 yearsFirefighter Ashley Stephens Age 20 yearsFirefighter Darren Yates-Badley Age 24 years

5

3) Sequence of events

This is a brief summary of the events of a complexincident, with many simultaneous activities beingcarried out. A full account of the incident can befound in the FBU’s full serious accidentinvestigation report into this tragic incident.

At approximately 17:20 on Friday 2 November 2007,the fire alarm panel activated at Wealmoor (Atherstone)Ltd indicating that a detector had operated in zone 11– the food storage/packing area. An employeetelephoned the engineering manager and he returnedto the site. When he arrived the premises were beingevacuated but he could see no evidence of fire so hesilenced the alarm. Within 10 to 12 seconds the alarmreactivated.

The engineering manager then went to investigate thefood storage/packing area, found a small pallet ofpackaging material on fire, emptied a 6 litre foam fireextinguisher and used a carbon dioxide extinguisher totry putting the fire out. He then went outside to get theassistance of some warehouse staff and together theyreturned to the food storage/packing area to find theflames from the pallet were now reaching the ceiling.They withdrew and decided to call the fire service.

At 17:35, 15 minutes after the fire alarm panel hadactivated, Gloucestershire Fire and Rescue Service(GFRS) received a call reporting a fire at Hangars 1 and2, Atherstone Industrial Estate, Atherstone on Stour,Warwickshire. GFRS established from the caller that itwas a building on fire and that normal operations atthe premises were the washing and packing ofvegetables for supermarket retail outlets. Contact withthe caller was terminated, but a mobile phone numberwas available. At 17:37 GFRS informed WarwickshireFire and Rescue Service (WFRS) of the incident.However, GFRS did not pass on to WFRS all of theinformation received. Hangar 1 was also locally knownas Bomfords.

The original part of the building was a World War 2aircraft hangar which was extended in 2000 by its thenowners Bomfords Ltd doubling the size of the originalhangar. In 2005 Bomfords Ltd refurbished the existingbuilding and began construction of a further extensionof a large steel-framed building, increasing its overallsize to approximately 150 metres by 69 metres.

The local authority building control never issued acompletion certificate for the extension although thisis not unusual. During the construction of theextension Bomfords Ltd went into administration(June 2007).

In August 2007, Wealmoor (Atherstone) Ltd purchasedthe business and was the owner at the time of theincident. The interior of the extension was stillincomplete.

The new extension was of a steel frame sandwich panelconstruction. It had two levels with some wall andceiling partitioning on both levels created usingEurobond 100mm Rockwool sandwich panels. The firstlevel floor constructed of 38mm chipboard fixed to Csection floor joists which were fixed to the steelbeams. This created a 500mm void between the floorlevels. All sandwich panel joints on ceilings and wallswere finished with plastic cover strips to comply withhygiene regulations. In the office areas some timberstud partitioning with plasterboard walls were used.

At 17:41, 21 minutes after the fire alarm panel firstactivated and 6 minutes after the call reporting the firewas received by GFRS, two appliances from Stratfordupon Avon (351 wholetime water ladder and 352retained water tender) were mobilised for a building onfire at Hangars 1 and 2.

The first crew arrived (351) at the incident at 17:51 –31 minutes after the fire alarm panel first activated and16 minutes after the initial fire call was made to the fireand rescue service. The lighting and weather conditionswere dark and dry and the temperature wasapproximately 5°C. The only artificial lighting was thatshed from the internal premises and provided by theappliance’s own lighting systems.

On arrival the watch manager (WM) became the incidentcommander (IC) and he was faced with a large propertywith internal lights on and no obvious external signs offire. He was met by the engineering manager, who toldhim that there was a pallet full of cardboard on fire onthe first floor and that there weren’t any people insidethe building. The engineering manager also told thewatch manager that the power and ventilation fans hadbeen isolated and that he had attempted to extinguishthe fire with a six litre foam extinguisher and a twokilogramme carbon dioxide extinguisher which were leftby the doors to the fire compartment.

The watch manager and a firefighter (FF) accompaniedthe engineering manager into the building via thepremises’ public entrance (which later became EntryControl Point Red) and ascended the stairs on the righthand side which took them to the first floor. Then theypassed through an office (the reception area) and a setof double doors opening onto a long corridor andturned right. The corridor contained two sets of fire

6

doors and was illuminated by internal lighting systems.At this time the corridor was clear of smoke, but smokewas observed at the end of the corridor issuingthrough the gap between a third set of double doors,which were the entrance to the lift lobby area and firecompartment. The engineering manager gave noinformation on the distance to the fire from the liftlobby area double doors.

The distance to the pallet on fire was later discoveredto be approximately 73 metres from the lift lobby areadouble doors. It transpired that the fire loading in thestorage/packaging area was far greater than a singlepallet. The pallet on fire was one of 22 pallets, locatedtogether to the rear of the storage/packaging area andcontaining labels, cartons, and punnets and wrappingfilm. The property cleaning materials, some furnitureand old computers from another site owned byWealmoor were also stored in this area. Had thisinformation been given to the watch manager at thistime it would have provided an indication of the size ofthe compartment and the potential hazards.

When he returned from the corridor near to the liftlobby doors the engineering manager omitted toinform the watch manager and FF of the alternativefirst floor fire exit to their left. If this fire exit had beenused as the initial entry point crews would have beenapproximately 40 metres closer to the firecompartment with a less congested route. Thisentrance was later used by crews from Hereford andWorcester Fire and Rescue Service (HWFRS) whichbecame BA Entry Control Point Green.

Three firefighters connected both appliance hose-reels(combined length totalling 120 metres) from the waterladder pump (351) and were assisted by the retainedcrew (352 now being in attendance) to drag the hose-reel up to the first floor via the same public entranceand staircase which the watch manager and theengineering manager had used previously.

The watch manager decided to commit two firefightersdonned in breathing apparatus (BA) with the extendedhose-reel. BA team 1 were committed to the firecompartment, and were designated as Red 1. Thewatch manager – without wearing BA himself –accompanied BA team Red 1 to the corridor leading tothe fire compartment on the first floor. En-route hebriefed the team that there was a pallet on fire andthat they were to locate and extinguish the fire.

BA team Red 1, took the hose-reel and proceededalong the corridor, which at the time was clear of

smoke, through two sets of double doors, which hadbeen previously propped open with fire extinguishers.When they reached the end of the corridor they werefaced with a further set of double doors leading to thelift lobby area and they observed wispy smokeemerging through the doors around the edges.

Through the door, BA team Red 1 found there was zerovisibility and proceeded on their hands and knees.Progress was extremely slow and they had to keepreturning together to the lift lobby double doors to pullmore hose-reel into the fire compartment. One of thefirefighters in the BA team found a pallet to prop thedoors open to stop the hose-reel becoming jammed inthe doors. Unable to locate the fire, BA team Red 1requested the thermal imaging camera. The camerawas brought up to the first floor by the watch managerwhere part of the way down the corridor he met BAteam Red 1. When the BA team used the camera withinthe fire compartment, the screen appeared to beblank. Both team members checked this, althoughwhen panning, and in the process of passing thecamera between them, one of the firefighters recalledseeing a flash of red on the screen when facing thedouble doors. The BA team estimated that they hadmanaged to travel about 5-10 metres inside thecompartment on their hands and knees, and becausethey were becoming low on air they decided to exit thebuilding.

Meanwhile outside, the engineering manager hadinformed the watch manager of a large water tank onthe far side of the building containing approximately16000 litres of water.

Between 18:19 – 18:30 – approximately one hourafter the fire alarm panel was first activated – twofirefighters from the retained crew of 352 wereinstructed to form the second BA team (Red 2). Theywere instructed to take the two 60 metre lengths ofhose-reel from the water tender 352, connect them (tomake a 120 metre length) and lay a second extendedhose-reel to the right hand side of the corridor up tothe doors of the fire compartment and not to enter.They were then instructed to liaise with BA team Red 1when they emerged and, following passing over ofinformation, they connected their additional hose reelto the original hose-reel (extending to make a 240metre length of hose-reel) and attempted to locate thefire. The firefighters in BA team Red 2 said that thisoccurred just outside the fire compartment and thatthey were told to “take care it’s hot in there”.

7

BA team 2, Red 2 advanced into the compartment ontheir knees, and gas cooled as they progressed. Waterdroplets came down. Again nothing could be seen onthe thermal imaging camera. BA team 2, Red 2 thenadvanced about three or four yards and when thefirefighter gas cooled there was no return of waterdroplets which made him think it was either a verylarge room or it was hot. He then gave four long pulseswith still no water droplets returned. BA team 2, Red 2were concerned and felt that something was not quiteright. One firefighter told the other: “Just soak it, so I didand we were hit with a wall of heat which made me fall to mybelly.” With this intense heat and the base of the smokelayer now down to shin height Red 2 decided that theconditions had changed significantly and collectivelydecided to withdraw.

18:26 The watch manager made up for a third pump:“as we are having difficulty locating seat of fire due to size ofpremises.”

18:29 Station Manager (SM) confirmed that he wasproceeding to the incident.

Given the information from the previous BA team, thewatch manager again asked the engineering managerabout the layout and size of the fire compartment, asthe BA teams were having difficulty locating the fire.The engineering manager then indicated from theoutside where the compartment started and paced thearea out along the building.

Firefighters from BA team 1, Red 1 also spoke to theengineering manager about the layout of the firecompartment. That discussion highlighted thecomplexity of the building. If the distances given bythe engineering manager were accurate it meant thatBA teams still had at least 35-40 metres to travel tothe seat of the fire once inside the fire compartment.

The actual distance from the lift lobby doors to the firewas approximately 73 metres.

The engineering manager drew three plans for crews onthat night (all different) but omitted the lift lobby areaand the four-hour fire wall and also gave the incorrectlocation and distance of the fire. At no point did heoffer the dimensions of the compartment or theadditional pallets (fire loading).

At approximately 18:30 BA team 2, Red 2 exited thebuilding after about ten minutes in the firecompartment and showing signs of anxiety.

A firefighter from BA team 1, Red 1 recognised thesigns of anxiety exhibited by both firefighters from Red2, and approached one of the firefighters to try andcalm him down. Initially the firefighter thought thatthey had returned for a piece of equipment. However,once he had established that this was not the case, heinstructed the firefighter to remove his BA facemask.

The reason given by, BA team 2, Red 2 for their earlywithdrawal was that they were low on air due to layingout the hose-reel before being committed into the firecompartment. They also stated that they were: “unableto locate the fire and that the room was still hot”.

The watch manager decided he was going to commit afurther BA team and started to see who was availablefrom the crews at the incident. With the informationthat they had gathered, BA team 1, Red 1 firefightersvolunteered to go back in. The watch manager initiallysaid no to the firefighters due to their previous wear.However, once he had checked that they were bothfully fit for the task, they were committed for thesecond time. The team were designated Red 1 again.

The watch manager and firefighter from the secondappliance (352) having completed their 360°reconnaissance advised the watch manager in chargethat: “Other than smoke issuing from fan apertures, thereappeared to be no other physical signs of the fire developing inother parts of the building.”

At approximately 18:34 the original BA team 1 wererecommitted and identified as Red 1 again. They weregiven the same brief as previously. Both firefightersalso believed that they were better equipped with theknowledge from their previous entry. The team retracedtheir steps to the first floor and located the hose-reelleft by Red 2 at the top of the stairs in the receptionarea. The firefighters had formulated a plan from theinformation that they had received from theengineering manager. Once inside the lift lobby area,they were going to deviate slightly left in a diagonaldirection until they reached the wall 5 metres insidethe lift lobby area. Then they would turn right along thewall until they reached the opening in the four-hour firewall. This method would be repeated to reach the endof the 9-metre wall which leads to the fire on the plandrawn by the engineering manager. They believed thatthe fire would be approximately 10-15 metres past thatwall (although it has been established since that theengineering manager was wrong about the location ofthe fire). With this plan in mind, they thought that theobjective was achievable. However, their main concernwas preventing the team from becoming lost.

8

The watch manager in charge followed BA team 3, Red1 up to the first floor and noted that: “The smoke at thispoint had spread approximately half way down the corridortowards the reception area, but it was still possible from acrouched position to see within a few metres of the firecompartment.”

BA team 3, Red 1 entered the fire compartment andfound that there was thick black smoke down to thefloor which became even hotter once they had passedthe rear lift lobby wall. The BA team 3, Red 1 couldhear things falling from the ceiling. One of thefirefighters helmet torch became entangled in cables,believed to be from the lighting systems, which werehanging down. These were surface mounted in plasticconduits. It took quite some time to free the firefighterfrom the cables. The conditions were so poor hecouldn’t see where the cables were coming from, buthe saw something white floating in front of him whichhe believed to be a light fitting. They both experiencedan increase in temperature at this point. The secondfirefighter stood up to step over the cables and couldfeel a further increase in temperature. Back on theirknees they took the same route as before. Thefirefighters reached a triangular shaped structure,which was hot; they radioed the Breathing ApparatusEntry Control Officer (BAECO) for information about itsidentity. The firefighters described the conditions: “Myears were slightly burning through my flash-hood and myhands starting to scald in wet gloves.”

The BAECO asked the engineering manager what thehot triangular object was and for any otherinformation. The engineering manager stated that: “Idon’t know of anything that could be triangular, I think theremay have been a pallet truck up there but I’m not sure.”

As there was no additional information available toassist the BA team 3, Red 1 and with the conditionsdeteriorating, the firefighters decided to withdraw andat approximately 18:50 – approximately an hour and ahalf after the fire alarm panel activated – they exitedthe building, leaving the hose-reel in the reception areaand still not having located the fire. During the debriefwith the watch manager night shift, the firefightersstated that it was the hottest fire that they had beento for years and that there was zero visibility inside thefire compartment.

At 18:34 the relief crew from the night shift fromStratford booked in attendance to relieve the day shiftcrew.

The two watch managers (day shift and night shift)both agreed that the incident should progress toCommand Level Two (5 pumps plus 1 for commandsupport, and a fire cover officer).

At 18:37 the third pump 371 Alcester (retained WaterLadder) booked in attendance.

The watch managers began the formal handover ofinformation. However, watch manager day shiftremained in charge whilst watch manager night shiftassisted with the allocation of tasks for the oncomingappliances and the organisation of crews. When theAlcester pump arrived, watch manager night shiftinstructed the watch manager that he wanted two BAwearers. The watch manager also requested the twohose-reels off the Alcester pump and to connect thishose-reel line into 351.

FF Stephens and FF Yates-Badley from Alcester crewvolunteered to wear BA.

The engineering manager also told the watch managerday shift of an alternative access point that wouldrequire entry through the ground floor to open thedouble fire exit doors which could only be openedfrom the inside. The watch manager and theengineering manager went and looked through thetransport office window into a large area known as‘goods out’. This large room was clear of smoke withno signs of fire. They entered from a roller shutter doorto the left of the loading bays into an open area knownas the ‘goods out area’.

They progressed diagonally to the right through thegoods out area and opened the fire doors which wereapproximately 18 metres to the right hand side of theexisting entry point.

The watch manager day shift requested the attendanceof a water bowser, which contained 5,400 litres ofwater, as it was unclear if the onsite water supplywould be available or suitable. The water consumptionon the fire ground was not excessive and it appearedthat the water from the appliances in attendance wascoping with demand. No fire hydrant had been setinto; the nearest two fire hydrants were located on theA3400 Shipston Road, one 260 metres (13 lengths ofhose) away across a field with the hydrant postshowing a 75mm water main, and the other on thejunction with the access road some 915 metres (45lengths of hose) away, with the hydrant post showing a90mm water main.

9

At 18:48 401 Wellesbourne (retained Water Ladder)booked in attendance.

The watch manager night shift instructed watchmanager from Wellesbourne to provide two hose-reellengths to 351 and two BA wearers which were to bethe BA emergency team, and to instruct the rest of thecrew to find the emergency water supply behind thebuilding in the woods.

Water from 401 Wellesbourne pump was provided to351 Stratford.

18:49 The watch manager night shift sent a furtherassistance message: Command Level 3 (eight pumpsplus control unit with pump to support it) the controlunit was off the run.

18:50 WFRS fire control contacted Hereford andWorcester Fire and Rescue Service’s fire control centre,requesting the attendance of one appliance as part ofthe pre-determined attendance for the Command Level3. Hereford and Worcester Fire and Rescue Service’spolicy states that a minimum of two appliances and astation manager will be mobilised for any cross-borderworking. This is to ensure HWFRS’s own safe systemsof work are implemented and fully resourced, this iswhat they mobilised to the incident.

At approximately 18:51 the watch manager night shiftformally took over as incident commander.

At 18:51 the station manager booked in attendance;he observed: “I noticed light grey smoke issuing from theeaves but nothing that gave me any major concern. There wasenough evidence to confirm that there was a fire of some degreeinside the building”.

18:51 341 Shipston on Stour (retained Water Ladder)booked in attendance.

The watch manager night shift requested a further BAteam (BA team 4) to be of four wearers for hosemanagement due to the long travel distance to thescene of operations. The BA team consisted of WMReid and FF Averis from Stratford, and FF Yates-Badleyand FF Stephens from Alcester.

They were the fourth BA team to be committed andwere also designated with the call sign Red 1 (BA team4, Red 1) and recorded the entry time of 18:53 on theentry control board. The watch manager night shiftbriefed the BA team to: “Carry out a right hand search ofthe fire compartment and tackle the fire and use the originalhose-reel which had been left at the top of the stairs in thereception area”.

18:55 361 Bidford on Avon (retained Water Ladder)booked in attendance.

Before BA team 4, Red 1 entered, a firefighter from BAteam 1 had a discussion with WM Reid about theconditions and layout inside the building. Thefirefighter drew a sketch plan of the layout onlaminated sheets of paper from a command supportpack. This indicated the premises’ doors, corridors, thepartitioning walls inside the fire compartment and thecables that were hanging down from the ceiling, whichthe firefighter had got caught up in.

At 18:58 291 Leamington Spa (wholetime WaterTender) booked in attendance and a group managerwas mobilised to attend the incident.

Meanwhile, a firefighter recognised additional waterwas required and started to ferry appliances from theholding area so that the water from the on board tankscould be used.

At approximately 19:00 the station manager tookcommand of the incident from the watch managernight shift. He instructed the on-site water tank to belocated and examined to see if it could be used toprovide water. The tank was located in the woods butthe type of connections was found not to becompatible with the fire service connections.

At approximately 19:07 BA team 5, also called Red 2,consisting of another mixed crew from two differentWFRS stations were committed with a call sign Red 2.Their brief, provided by the watch manager night shift,was to enter the building with a second hose-reel andcarry out a left hand search upon entering the firecompartment.

19:10 294W wholetime Leamington Spa Water Bowserbooked in attendance.

19:10 292 Leamington Spa (wholetime Water Ladder)booked in attendance.

After searching the canteen area on the left off thecorridor, BA team 5, Red 2 went through the doubledoors into the lift lobby area. The smoke was down tofloor level with zero visibility and the heat wasdescribed as being: “intense” and: “a punch on the nose”also: “like an oven” by BA team 5, Red 2. The crewmanager leading the team noticed a hose-reel alreadygoing through the double doors and then off to theright. Whilst gas cooling by the double doors, the crewmanager could hear BA team 4, Red 1 communicatingwith each other at about 45° in front of him. The

10

communicating sounds gave the crew manager theimpression that everything was as it should be with theBA team 4 Red 1 at that time.

About 2-3 metres inside the compartment BA team 5,Red 2 were unable to pull sufficient hose-reel tocontinue into the fire compartment. The firefighter whohad the hand-held radio tried to contact the BAECO formore hose-reel, but he received no reply. He alsocommented on the conditions being hot and theconfusion of hearing several messages from unidentifiedvoices. The team returned to the corridor to pull somemore hose-reel through. It appears that there had beena problem with hose management somewhere in thecorridor. This became apparent later in the incidentwhen other BA teams encountered similar difficulties.The firefighter who was number three in the BA team 5,Red 2, noted that: “Due to the density of the smoke he couldnot even see the FF who was number 2 and who in reality wasbarely a few feet in front of him”.

Returning to the fire compartment the crew managerentered the compartment and travelled about four orfive feet and carried out a Dynamic Risk Assessmentdue to the fact gas cooling appeared to be having noeffect on the level of heat and smoke and he couldhear large objects falling down. The crew managerconsidered the reasoning behind crews beingcommitted inside and decided it was not worth therisk. He spoke to firefighter number 2 in the team, theywere both taken aback by the heat and decided it wasworthless to proceed any further.

The BAECO tried to contact BA team 4, Red 1 via thehand-held radio. He received a garbled message thathe could not understand. He went to the watchmanager night shift who was standing nearby andcommunicated his concerns. The watch manager tookthe radio from the BAECO and tried to contact BAteam 4, Red 1 who responded “emergency, emergency”.This was the last radio communication received fromBA team 4, Red 1.

The station manager was informed by the BAECO ofthe BA emergency and instructed the watch managernight shift to redirect BA team 5, Red 2 in order toassist BA team 4, Red 1.

The BA emergency message was received by firecontrol at 19:14:51 – approximately 22 minutes afterBA team 4, Red 1 had been committed.

BA team 5, Red 2 returned to the double doors tocommunicate their decision to withdraw but they heardthe BA emergency prior to sending their message they

reconsidered their decision and re-entered thecompartment to assist BA team 4, Red 1, leaving 2members of the BA team to manage the hose-reel bythe double doors.

With their backs to the door facing into thecompartment, they could hear BA team 4, Red 1. Fromtheir original location BA team 4, Red 1 appeared tomove across in front of them from right to left at adistance of several metres, although this isapproximate as they could only hear the BA team andnot see them because of the conditions in thecompartment.

The crew manager and firefighter number 2 grasped thehose-reel and proceeded along the left hand wall. Theywere shouting: “Red 1” and spraying water in thedirection of the noises to try to attract their attention.The crew manager also waved his torch and shouted.

After about 10 metres the crew manager and firefighterof BA team 5, Red 2 ran out of hose-reel. Theyreturned to the other two BA team members by thedouble doors and attempted to pull some additionalhose-reel but to no avail. The crew manager andfirefighter once again set out on a left hand searchfrom the double doors with the same amount of hose-reel, with the crew manager continuing to wave historch and shout.

A few metres along the left hand wall a firefighter(since identified as WM Reid) appeared out of thesmoke. He was bent over but on his feet stumblingtowards them about to hit the floor. The crew managerstated in court: “I put my right hand onto his left shoulderand scooped him up and got him up and got him onto the leftwall, the reference wall. I turned around to the wall with theintention of getting him out as a casualty; he was bent doublefacing the doors. He then rushed off towards the doors”.

WM Reid somehow gathered momentum and made hisway along the wall past the two firefighters who werehose managing by the double doors and disappearedthrough the doors. The two firefighters did not see inthe smoke-logged corridor which direction WM Reidwent.

The crew manager and firefighter knew that other BAwearers were in a similar location as they could hearone or two distress signal units (DSUs) activating in thedistance. So he and the firefighter decided that theywould continue along the left hand wall. As theyproceeded, they were banging the wall, shouting andwaving their torches. At the same point they ran out ofhose-reel but nevertheless decided to continue along

11

the reference wall. The crew manager realised whatthey were doing increased the risk to them.

With their BA sets becoming low on air and hearing nofurther noises from the remaining firefighters of BA team4 or sounds from the DSUs, the crew manager andfirefighter reluctantly decided to withdraw. They reportedthat they had left the hose-reel where it was for tworeasons: “Firstly as a means for the remainder of the BA team4, Red 1 to withdraw, should they be able to locate it. The otherreason was that they were too knackered to bring it out”.

Making their way back down the corridor towards thereception area, BA team 5, Red 2 came across BA team8, Red 4. The firefighter leading the team out asked BAteam 8, Red 4 if a firefighter had passed them. Afirefighter from BA team 8, Red 4 replied “no”. Thefirefighter from BA team 5, Red 2 said “He must besomewhere between where they were and the fire compartment”.BA team 8, Red 4 continued along the corridor andpassed through the second set of double doors. At thispoint either the hose became snagged or it was at itsfull extent. They could hear a DSU sounding, so theydecided to split the team into two teams of two. Twofirefighters remained with the 45mm jet, whilst theother two firefighters continued along the corridor untilthey came to another corridor which went off to theleft just before the double doors into the lift lobbyarea. They proceeded a short distance down thiscorridor, where they found WM Reid: “There was no air leftin WM Reid’s cylinder by looking at his gauge, and the factthat the BA set low-pressure warning whistle was not operating.The face mask was still covering his face, his fire helmet wasdislodged and they could see no sign of him breathing”.

The two firefighters then began dragging WM Reid fromthe incident.

At 19:25 the BA Main Control Officer (BAMCO, astation manager) booked in attendance. He reported tothe station manager in command of the incident thathe would be unable to carry out BA Main Controlduties until the BA pod arrived. Instead he was taskedwith assisting with the BA entry control point. Between19:25 and 19:35, the station manager (BAMCO)assessed that the BA situation was not “looking like agood situation”.

At 19:26 BA team 5, Red 2 exited the building andcollected their BA tallies.

19:28 was the predicted time of whistle for the missingBA team 4, Red 1 – approximately fourteen minutesafter the BA emergency message was received by firecontrol.

At 19:31 the mixed crew of wholetime and retained(day crewing system) Evesham pump booked inattendance.

At 19:32 the Warwickshire group manager and theretained Pebworth pump from Hereford and Worcesterbooked in attendance. The Pebworth crew wereinstructed to set up a second BA entry control point atthe subsequent entrance door used earlier by theengineering manager and the watch manager with theshorter travel distance to the lift lobby double doors.

Also at 19:32 261 wholetime Rugby appliance bookedin attendance.

At 19:36 the BA pod booked in attendance.

There is some confusion as to the hand-over ofincident command from station manager to groupmanager during this period and some difficulty wasexperienced in maintaining water supplies for BAcrews.

At between approximately 19:34 – 19:37 anemergency BA team – BA team 9, Green 1 even thoughthey entered from BA entry control point Red – wereabout to enter the building but were delayed as BAteam 8, Red 4 had exited with WM Reid. Franticattempts were made immediately to revive WM Reid bythe entry point door.

BA team 9, Green 1 then entered the building andmade their way down the main corridor where theycould hear the sound of activating DSUs. Theycontinued into the fire compartment experiencing:“Really thick smoke and heat as if like going into an oven”.

At 19:40 BA team 10 were committed to lay aguideline and search for the missing firefighters. Forsome reason they were also given call sign Green 1even though they had entered from BA entry controlpoint Red.

The incident continued to develop, the conditions inthe fire compartment deteriorated, water supplies forBA crews were problematic, further BA teams werecommitted and command and control appeared to beconfused.

At 19:42 381 Studley (retained water ladder) booked inattendance.

Between 19:52 – 20:00, the station manager briefedthe group manager, including that three members ofBA team 4, Red 1 were missing on the first floor.

12

At approximately 19:55 – 20:00, BA team 11, Green 1were the first BA team to enter through the second BAentry control point set up by Hereford and Worcester,which they were told to call Entry Control Point Green.They were delayed whilst awaiting a hose reel to be setup.

At 19:56 the chief fire officer booked in attendance.

Between approximately 19:56 and 20:10, BA team 12were committed. They were delayed by a loss of water.

At 19:59 the group manager made pumps 12.

At 20:01 the group manager made pumps 16.

At 20:02 WM Reid was taken by ambulance tohospital.

At 20:10 the station manager (BA Main ControlOfficer) established BA Main Control. He believed:“There was only one entry control point in operation beforeBAMC was set up and the second entry control point (H&W)was designated White and he believes that they were in stage 2BAECO procedures.”

At 20:12 the group manager sent an informativemessage that: “Building used as warehousing, approximately200m x 300m, fire in roof area, attempts being made by crewsto source a reliable water supply, three firefighters unaccountedfor, Oscar offensive mode.”

At approximately 20:37 – 20:51, BA team 13, Green 2were committed. Two of the team entered the firecompartment area: “…crawling on their hands and kneestowards the sound of the DSUs due to the heat where theyfound two firefighters opposite to the entrance of the lift. Thecasualties were both on their backs with one slightly over theother and their torches still illuminated, the BA set gaugesshowed zero, both still had their face masks and helmets on.There was no firefighting media with the casualties and nodebris around them.”

At 20:51 BA team 13, Green 2 informed BAECO thatthey had located two casualties – this almost an hourafter BA team 4, Red 1 had been committed and morethan half an hour after the BA emergency had beendeclared. The BA team felt the casualties and foundthem to be “stiff”. They considered the casualties to bedead and should be left as the area was a potentialcrime scene. They were too low on air to remove thecasualties from the building. As they were withdrawingthey became concerned at the noises they were hearingfrom the building that seemed to be coming from abovethem. As they were leaving the lobby area the rumblingsound became louder: “It sounded like a collapse…”

Two further BA teams – 14 and 15 – were committedby the group manager to attempt retrieval of thecasualties but after entering they withdrew themselvesdue to the deteriorating conditions.

At 21:10, the deputy chief fire officer sent aninformative message confirming his assumingcommand and “details as before, eight BA in use, searchbeing carried out on first floor, two casualties have been locatedand being brought out, one person still unaccounted for, locationof fire not yet identified, Oscar mode.”

At 21:14 an amendment was sent: “Three persons stillunaccounted for.”

At 21:22 a further informative message was sent fromthe deputy chief fire officer: “Following dynamic riskassessment based on information from BA crews, internal floorsand ceilings are in danger of collapse, all BA teams withdrawn,water supply now located, water relay being set up using HVP,Delta mode.”

The bodies of the three remaining firefighters – FFAveris, FF Yates-Badley and FF Stephens – wererecovered four days later.

13

17:20 Fire alarm panel activated

17:37 Call to Warwickshire Control

17:51 1st pump (WT) in attendance

17:54 2nd pump (RDS) in attendance

18:26 Make pumps 3

18:37 3rd pump (RDS) in attendance

Command level 2 message5 pumps plus one pump for command support

18:48 4th pump (RDS) in attendance

18:49 Command level 3 message8 pumps plus control unit

18:55 5th pump (RDS) in attendance

18:58 6th pump (WT) in attendance

19:10 7th pump (WT) in attendance

19:14 BA emergency declared + 2 pumps

19:31/32 8th and 9th pumps Evesham (mixed crew) and Pebworth (RDS)from Hereford and Worcestershire in attendance

19:32 10th pump (WT) in attendance BA emergency pump

19:42 11th pump (RDS) in attendance BA emergency pump

19:59 Command level 4 message12 pumps

Timeline

14

4) Evidence collection

The evidence collected to support the above sequenceof events and which informs the reportrecommendations has been obtained and collatedfrom the following documents:

l Police witness statements.

l Notes taken by FBU officials at Police/Health andSafety Executive interviews with FBU members.

l Tape recordings of Police/Health and SafetyExecutive interviews with FBU members.

l Witness Statements and supplementary evidenceprovided to FBU Serious Accident Investigationteam.

l Warwickshire Fire and Rescue Service (WFRS)individual statements “G1”.

l Notes made by individual incident attendeesfollowing the incident (contemporaneous notes).

l WFRS printed incident message log.

l WFRS audio log of incident.

l WFRS individual training records.

l Photographic evidence.

l Building plans.

l WFRS policies and procedures.

l National Guidance documents for the Fire Service.

A joint investigation was carried out by WarwickshirePolice, and the Health and Safety Executive. Herefordand Worcester Fire and Rescue Service lead in dealingwith the fire investigation/cause of fire.

In addition to legal representation, FBU officials werealso present at all the police interviews with FBUmembers, except interviews carried out by the policeimmediately following the incident on the 3 and 4November of Hereford and Worcester crews. A largenumber of firefighters were interviewed on two or threeseparate occasions. All interviews were tape recordedby the police and the FBU.

15

5) Analysis

5.1 What happened?

Evidence from the pathologist’s report established thecause of death:

l Ian Reid – smoke inhalation and asphyxia.

l John Averis, Darren Yates-Badley, AshleyStephens – conflagration, including all possibleconsequences of fire death, e.g. asphyxia,inhalation of smoke, heat exposure, injury fromdebris etc.

5.2 How did it happen?

Warwickshire Fire and Rescue Service (WFRS) weremobilised to a pallet on fire in a building onAtherstone on Stour industrial estate.

WM Reid, FF Averis, FF Yates-Badley and FF Stephenswere BA team 4, Red 1 who were committed from EntryControl Point Red.

The BA team were briefed to “Carry out a right handsearch of the fire compartment and tackle the fire”.

They progressed to the lift lobby area on the first floorof a non-combustible sandwich panel building 150m x69m with a hose-reel.

The compartment had a complex layout, it was hot andheavily smoke logged. The fire had been burning forapproximately 90 minutes before they were committed.

The team entered the compartment and for someunknown reason they became separated from thehose-reel due to worsening conditions within thecompartment and were unable to find their way out.

A member of BA team 4, Red 1 raised a BA Emergency,but it is unknown if this was before they left the hose-reel.

WM Reid was brought out of the building by asubsequent BA emergency team.

Two other members of BA team 4, Red 1 were locatedat 20:51 but were unable to be recovered.

The three remaining firefighters were recovered fourdays later.

5.3 Why did it happen?

There are many layers of causes ranging from thespecific actions of individuals at the scene to strategicdecisions made by senior managers and the fire andrescue authority years before the event.

National Frameworks are written for the fire and rescueservice by the Secretary of State under powersdescribed in Section 21 of the Fire and Rescue ServicesAct 2004. The National Frameworks 2004-5, 2005-6and 2006-08 contained guidance on the role and thedetail that should be contained in an Integrated RiskManagement Plan (IRMP).

The IRMP is the overarching document that shoulddescribe the systematic process for strategic planningand the delivery of an efficient, effective and safe fireand rescue service. It is therefore the IRMP that will beconsidered first in the examination of the causes andfindings.

The next layer of the causes and findings below theIRMP includes specific organisational issues such asthe collection of operational risk information, IncidentCommand System, training etc. However the suitabilityof the IRMP must be examined first because the IRMPshould encompass the specific managerial issues. Ifthe IRMP process had been followed through properlyby WFRS, specific issues such as those statedpreviously would have been identified as inadequateand policies would have been put in place andresources allocated to deliver improvement.

Warwickshire Fire and Rescue Authority (WFRA)published IRMPs in 2004 and 2007. They containedstrategic objectives, but little in the way of planning.What they noticeably failed to consider was to plan forthe delivery of “business as usual” and for the capacityof the service to safely deliver its core business ofresponding to fires. In terms of operational policy then,the service was ‘coasting’ on the momentum built upin the years preceding 2004.

If in WFRS the IRMP process had been followedcorrectly in line with the FBU’s ‘The FrameworkDocument: How to construct an IRMP/RRP’, the issuesthat contributed to the incident would have beencaptured and the authority would have been betterplaced to deal with incidents of this nature.

16

The IRMP process should have considered many of theissues that now form part of the causes and findingslisted below:

l National Framework

l IRMP

l Risk information

l Incident Command System

l Dynamic Risk Assessment

l Breathing Apparatus

l Water supplies

l Operations

l Fire development and firefighting actions

However, the causes and findings that contributed tothe outcome must be measured against the basictraining individuals received, the developmentprogramme, monitoring and audit processes incombination with the actions that occurred thatevening. Individual performance can only be assessedagainst standards set by WFRS policies and serviceorders, which must conform to nationalstandards/guidance including the periods ofassessment.

5.3.1 National Framework

When Warwickshire Fire and Rescue Authority (WFRA)constructed their IRMPs they should have takenaccount of the current fire and rescue service NationalFramework and its associated guidance. WFRA planspaid limited cognisance to government guidancedespite this being a requirement of the frameworks.When Warwickshire’s control unit was ‘off the run’, noarrangements were put in place to share the controlunits of neighbouring authorities.

However the Warwickshire IRMPs failed to set out theauthority’s assessment of local risk to life in the firstplace. The business needs of the service thereforecouldn’t be driven by the IRMP, there could be nosetting out of the competencies required by staff andthe HR strategy could not reflect the needs set out inthe IRMP because no needs were set out. It istherefore little surprise that WFRS was ill prepared todeal with the fire at Wealmoor (Atherstone) Ltd.

Integrating IRMP into the business planning processand incorporating the whole planning process, servicedelivery and the review cycle is not simply a ‘burden’that was placed on fire and rescue services. WFRS hasthe role of protecting the public and their property. Fireand rescue services put the lives of their staff at riskwhen they undertake that role. IRMP is not a burdenon WFRS. It is a vital planning tool that ensures thatthe service works safely, efficiently and effectively whilemaintaining the competence and safety of itsemployees.

5.3.2 IRMP

Prior to 2002/03, fire and rescue services were requiredto meet national standards of fire cover and crewing.They observed the contents of Fire Service Circulars,Dear Chief Fire Officer Letters (DCOL) and fire servicemanuals which gave direction on detailed managementissues. They were inspected by an externalinspectorate of fire and rescue service professionals,who measured against national guidance andperformance indicators.

From 2002/03 those controls were all but removed.WFRS were given the freedom to set their ownstandards not only in terms of attendance atemergencies, but in terms of training, equipment, anda multitude of other things that were previouslydirected from the centre. This had to be agreed withWFRA, who have the responsibility for providing a fireand rescue service. However rather than allow thisremoval of control to result in a free-for-all, the Officeof the Deputy Prime Minister (ODPM) used the Fire andRescue Framework for England to say that WFRS hadto produce an IRMP and what government expectedfrom it. The 2006-2008 National Framework statedthese expectations of IRMP.

It should therefore be possible to find the strategicplanning for all of the above within WFRS’ planningleading up to November 2007, described within thepages of the IRMPs for the preceding years.

ODPM produced guidance to explain what it meant byan IRMP. If the guidance is examined in detail, it is clearthat an IRMP fulfils the function of a business plan.The reason for this type of structure is obvious. Fireand rescue services were being given the freedom tofunction without externally imposed standards ordirection on detailed management issues, so it wasincumbent upon them to take over those rolesthemselves in a structured, ‘businesslike’ way through

17

a process that followed tried and tested businessplanning principles.

IRMPs are typically written by fire and rescue servicemanagers, but they are actually ‘signed off ’ by the fireand rescue authority. WFRS published an IRMP in 2004to cover the periods 2004/05 and 2005/06 and anotherin 2007 to cover the period 2007/08 to 2009/10. As faras the FBU is aware, there was no IRMP to cover theperiod 2006/07. The 2007 IRMP alone cannot be usedas a source to describe the position of WFRS inNovember 2007. At the time, the 2007 IRMP was athree year plan which had only been running for eightmonths. In order to fully understand the strategicplanning of the organisation it is necessary toconsider the 2004 plan as well. These two planstogether describe three and a half years of planningcarried out by WFRS and signed off by the fire andrescue authority preceding the fire at Wealmoor(Atherstone) Ltd.

If WFRS had followed government guidance whenwriting their IRMPs in 2004 and 2007, somewhere inthose plans should be an explanation of how theyidentified Wealmoor (Atherstone) Ltd as a risk. How theeffectiveness of current preventative and responsearrangements were evaluated and how opportunitiesfor improvement were identified. There should alsohave been a determination of the resources that wererequired to meet these policies.

In summary, the 2004/06 IRMP promises the public ofWarwickshire very little other than a series ofexplorations, investigations and reviews that should,may or could happen. There is virtually noprioritisation and the resources required to deliver onits proposals are not discussed.

“Action plans” are supposed to be the short termimplementation plans for the content of the IRMPs,but Warwickshire’s 2004/05 and the 2005/06 actionplans do no such thing.

l It might be expected that “priorities” identified inan IRMP should be actioned first. But matters thatare described as “Priorities” in the 2004 to 2006IRMP are not even mentioned in the 2004/05Action Plan

l 7 of the 44 actions identified as necessary by the2004 to 2006 IRMP were not planned to bedelivered by either the 2004/05 or the 2005/06Action Plans.

The significance of ignoring commercial property as arisk at the early stages of the process was thatstrategies for safe intervention at commercial propertyfires were all but ignored.

In 2007, WFRA published a document that said on itsfront cover that it was the 2007 to 2010 IRMP for theservice. However the content bore no resemblance toODPM guidance on the content of an IRMP. That is, itdid not describe how the service would fulfil its role ina structured businesslike way. It did not fulfil thefunction of a business plan.

If WFRA had followed government guidance andproduced a true IRMP in either 2004 or 2007, theywould have identified existing and potentialforeseeable risks to the community. This would haveincluded the potential to have to respond towarehouse fires. Following the government guidance atrue IRMP would also have involved evaluating theeffectiveness of current preventative and responsearrangements. In doing so, WFRA would have identifiedthe fact that their fire and rescue services riskinformation system, their command and controltraining and their BA training were inadequate,knowledge and recording of the built environment waspoor.

Finally, the fire and rescue authority would haveidentified opportunities for improvement anddetermined policies and standards for prevention andintervention and they would have determined resourcerequirements to meet these policies and standards.However instead of producing structured businesslikedocuments that took over the functions devolved tothem from government, WFRS produced documents onbehalf of their fire and rescue authority, which said“IRMP” on the front cover but which actually containedhigh level strategic objectives and vision statementsthat were never translated into service delivery.

Other legislation and guidance that should have beencomplied with at the time to assist the fire authority inthe production of a risk management plan were TheHealth and Safety at Work Act 1974 and TheManagement of Health and Safety Regulations 1999.The events of 2 November 2007 at Atherstone onStour serve as a stark reminder of what can happen if afire and rescue authority does not follow the processof creating a suitable and sufficient IRMP.

18

5.3.3 Risk Information

Gathering of risk information is critical to the safemanagement of an incident. On the night of 2November 2007 information on Wealmoor (Atherstone)Ltd, Hangars 1 and 2, Atherstone on Stour had notbeen gathered and utilised by WFRS with sufficientdetail to provide safe systems of work for respondingcrews.

The Operational Assurance Service Assessment carriedout in 2006 identified that WFRS had not fullypopulated the Fire Service Emergency Cover (FSEC)model with data covering all commercial premises,therefore it was not possible to deliver a risk assessedIRMP. A lack of a robust system had been identifiedduring the Operational Assurance Service Assessmentwhere a high risk premises was identified and riskinformation had not been transferred to the centraldata base meaning that some crews attending thepremises would not possess all the updated riskinformation.

The OPDM produced health and safety guidance forfire and rescue services and part of that guidance wasVolume 3 of the Guide to Operational Risk Assessmentwhich included generic risk assessments (GRAs). Theintention of these GRAs was to inform the local riskassessment process.

There is no evidence available that WFRA acted on thisinformation on the risks associated with large volumebuildings and put suitable and sufficient controlmeasures in place to ensure the safety of employees.

A previous incident on 20 April 2007 at the premisesidentified a number of fire safety issues, which thewatch manager reported to the Stratford Area RiskTeam. A fire safety inspection was carried out andidentified sandwich panel construction. Thisinformation should have triggered service order OTI03.16.06, identifying a risk and implementing furtherprocedures, which ultimately, would have generatedrisk information which would have been available onappliances and station premises risk folder. Themoment that that inspection was completed WFRSknew everything that they needed to know about thedesign of the building and the risks to firefighters thatit entailed. Any ‘blame’ that might have rested with thedesign of the building was immediately transferred toWFRS at that point.

Sandwich panel construction would also have beenincluded as additional information on the turnoutsheet as a hazard, also identifying the operational risk

assessment applicable to the hazard. With thisinformation all crews attending the incident wouldhave been aware of the hazard before arriving.

5.3.4 Incident Command System

In 2007 the WFRS Incident Command System wasoperating to Fire Service Manual, Volume 2, Fire ServiceOperations, Incident Command, second edition.Operational Intelligence available en-route and at theincident ground from occupier was poor andmisleading.

Mr. Tenney (Engineering Manager for Wealmoor(Atherstone) Ltd) omitted to inform or provide plans ofthe premise to the watch manager of the alternativefirst floor fire exit until approximately fifty minutes aftercrews had arrived. This exit would have positionedcrews approximately 40 metres closer to the firecompartment with a less congested route. WFRSpersonnel received continued incorrect informationfrom Mr. Tenney throughout the incident. He hadworked at the premises for two years and was part ofthe project team who managed the building of theextension, where the fire first started, that wascompleted in April 2007. At no time did Mr. Tenneycorrect any of the misinformation that he delivered onthe night.

There was ineffective communication across all areasof the incident ground resulting in lost information andself deployment. Command support functions were notoperating effectively. There appears to be no structureand poor communication on sectorisation.

At 20:38, there were sixteen pumps in attendance and95 personnel including the chief fire officer on theincident ground and yet still no water supply securedand Command Support function not resourcedcorrectly.

5.3.5 Dynamic Risk Assessment

Concern in recent legal cases is that fire and rescueincident commanders’ decision making has beenbrought into question and left them vulnerable topotential prosecution. The problem here is not withthe legal system expecting perfect results but with thefire and rescue service nationally incorrectly assumingthat these assessments of risk by individuals aresuitable and sufficient to comply with their duties andprovide legal protection for the organisation, thus

19

placing a legal burden on the individual employeesmaking dynamic risk assessments.

Dynamic Management of Risk at Operational Incidents was firstpublished in 1998. This document was produced by theHome Office as part of their health and safety guidancefor the fire and rescue service. The process wasdescribed as: “The continuous process of identifyinghazards, assessing risk, taking action to eliminate orreduce risk, monitoring and reviewing, in the rapidlychanging circumstances of an operational incident.”

This process is not ‘stand alone’ and is the last level ofthree levels of risk management used by fire andrescue services. The guidance provides this descriptor:“In order to provide an acceptable level of protectionat operational incidents, brigade health and safetymanagement must operate successfully at three levels– Strategic, Systematic, and Dynamic.”

Dynamic Risk Assessment was used on the night forthe vast majority of decision making by all of theincident commanders (as no written risk assessmentsup until the end of offensive operations on the nighthave been located, and the firefighter running thecommand support function has stated not writing orreceiving any) and not just the three who facedprosecution.

On first arrival at an incident, even a well-trained,experienced incident commander with adequateoperational risk information will only have very limitedinformation about the specific incident that they arefaced with. So making an accurate risk assessment willbe impossible. What is actually happening is that anindividual is making an assessment of risk, to enablethe selection of the correct safe system of work to beintroduced. On occasion an individual, when makingthe early assessment of risk, will be wrong. The wrongcourse of action will be selected without sufficientcontrol measures to reduce the risk. Firefighters ormembers of the public may be injured or worse.

5.3.6 Breathing Apparatus

It is evident that inexperienced BA wearers werenominated and allowed to be committed into the riskarea to attack the fire. This was not challenged byanyone on the night. There was ineffective briefing anddebriefing of BA teams, BA wearers and insufficientpassage of information and recording of actions. Therewas confusion on naming and numbering of entrycontrol points (ECPs) and BA teams.

There was insufficient understanding of the effects ofrecommitting BA wearers with minimal rest periodbetween BA wears. Numerous BA teams werecommitted some of these teams comprised of BAwearers from different stations unknown to each otherand not numbering off before entering the firecompartment. BA teams were entering and leaving thefire compartment with no firefighting media.

There appears to be a lack of coordinated resourcingof BA requirements and gathering of information byMain Control. Also the BA holding area should havemoved from the ECPs to BA Main Control. Emergencyteams were deployed without any additionalequipment. WFRS had purchased 10 sets of EmergencyAir Supply Equipment (EASE) but they were notavailable at the incident. They were stored at WFRSheadquarters, were included on the Interspiro TotalCare Contract, but were not on the run. This positionhad been ongoing for several years.

Throughout the incident no Breathing Apparatus EntryControl assistants or communications officers wereidentified by the incident commanders’ riskassessment and put in place. The lack ofcommunication on the limited amounts of the hose-reel available in the lift lobby area left the issueunresolved and therefore hampered BA teamsprogressing.

5.3.7 Water Supplies

WFRS used a database called Aquarius 3 to holdinformation on hydrant location, the location of openwater sources i.e. rivers, streams and ponds and staticwater sources i.e. bore holes and static tanks. Thisinformation was gathered and provided by area riskmanagers and the fire safety team and received by thewater officer. Aquarius 3 could only be accessed by thewater officer during office hours.

Water supplies were given some cognisance. However asustainable supply was not secured in place until thedeployment of the High Volume Pump. This was closeto 21:00 hours. The nearest fire hydrants were locatedon the A3400 Shipston Road, one 260 metres awayacross a field and the other located on the junctionwith the access road some 900 metres away. A waterrelay or shuttle was not secured from either of thesehydrants prior to the BA emergency.

20

The onsite water supplies were a bore hole and a16,000 litre tanker which proved to be unusable on thenight. These should have been identified by the riskinformation process as to their suitability to assist infirefighting operations. There was no identifiedindividual responsibility for securing a sustainablewater supply during the initial stages of an incidentfrom single to multi pump attendances.

Appliances were ferried from the holding area tosupply water to the fireground pumps however theseappliances were not replenished leading to adiminishing supply on the incident ground. Water usagewas not communicated to the Incident or SectorCommanders which led to an impression that watersupplies on the incident ground were sufficient.

5.3.8 Operations

The thermal imaging camera displaying a white screencaused confusion, impacting on its operationaleffectiveness and conditions within the firecompartment.

A covering jet was not deployed prior to BA teamsbeing committed into the risk area and would haveproved ineffective if required. It was also supplied fromthe same appliance as the hose-reels.

Poor hose management leading to congestion andconfusion in the main corridor resulting in BAemergency teams not being able to penetrate the firecompartment.

Many personnel on the night operated in smoke insidethe risk area beyond BA entry control point. At nopoint was a forward control point considered or setupwith the information gathered about events on thenight. This lead to teams and individuals working in therisk area without adequate command and control orprotection against the conditions.

5.3.9 Fire development and firefighting actions

There is no evidence that any water was applied to thefire prior to defensive firefighting tactics. At thisincident there appeared not to be any unexpected firebehaviour for an industrial storage premises of thistype that would explain the tragic outcome of the fire.

Rapid fire growth, which may have occurred at thisincident, is becoming more common as building

techniques and materials change. However this effectis not being reproduced in training situations thusleaving firefighters exposed to foreseeable risk.

The internal geometry of the Wealmoor (Atherstone)Ltd building was unusual in that it did not comply withApproved Document B to the Building Regulations andwhat appear to have been insurer required fireprotection was incomplete. As such, there was onlyone means of escape from the first floor storage areawhere the fire was located (contrary to ApprovedDocument B), and this single means of escape wasthrough an opening in a four hour fire resisting wallthat had no doors fitted. But the deaths of the fourfirefighters cannot be attributed to any of the abovebecause firefighter safety does not rely on buildingdesign it relies on adequate firefighter training andappropriate equipment delivered to the incidentground at the right time.

The building sector is calling for ever increasing levelsof insulation due to government incentives. This alsodemands ever smaller numbers of leakage pathsthrough construction joints. Firefighting/fire behaviourtraining concentrates on small compartments. Thisdoes not prepare firefighters for the issues describedabove.

Gas cooling has become a common practice in the fireand rescue service. The principle being applied is thatshort bursts of water spray into the hot ceiling gases ofa compartment fire cool those gases and therebyreduce the risk of flashover and improve conditions forfirefighters.

However it must be pointed out that in a very largecompartment on fire, there will be an enormousamount of energy in the hot smoke layer at ceilingheight. “Gas cooling” by short bursts of water sprayfrom a hose reel branch is going to have no noticeableeffect on the ceiling gas temperature, but it is going toincrease humidity in the immediate vicinity of thefirefighters who are using the hose reel.

Since humid air is a better conductor of heat than dryair, gas cooling in a very large compartment on fire isnot going to cool fire gases, it is not going to reducethe risk of flashover but it is going to worsenconditions for firefighters.

21

6) Conclusions

6.1 Specific conclusions

6.1.1 IRMP

Fundamentally, the events on that fateful evening of 2November 2007 were a catalogue of organisationalsystemic failings. The disaster started with the failureto deliver an effective IRMP prior to the incident, whichshould have identified Hangars 1 and 2 as a significantrisk to firefighters. This responsibility lies not only withWarwickshire Fire and Rescue Authority (WFRA) but withcentral government to ensure sufficient funding is inplace to deliver an effective, monitored IRMP. Riskinformation/fire plan would also have been available ifthe IRMP process had been applied correctly. With thecorrect application of the IRMP process the sufficientfunding, risk information and resources required todeal with such a significant risk would have been inplace. Subsequently this would have also highlightedthe training required to deal with such an incident tobring it to a safe and satisfactory conclusion.

6.1.2 FSEC

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

6.1.3 Training

Training within WFRS was also a significant factorcontributing to the failures within the organisation. Theareas that were identified were predominantlysurrounding the functions that were carried out on theevening of the 2 November 2007. These were riskinformation, risk assessment, breathing apparatusprocedures/command and control and incidentcommand. Quality assurance of the training deliveredin WFRS had also been identified as a significant issue.

6.1.4 Risk assessment

WFRS had a service order (03.16.06) that details theprocedure for operational premises risk assessment.A building of sandwich panel construction is seen as asignificant hazard requiring the minimum of theproduction of an O2 risk information card or possibly amore detailed fire plan of the premises. This procedurefailed on two occasions. Firstly, local building controlat planning stage, where all of the hazards aligned withthis type of construction should have been identified.Secondly, as a result of a previous incident a fire safetyofficer carried out an inspection of the premises due tofire safety issues that were identified, during thisinspection it was recognised that the building was ofsandwich panel construction. Both occasions shouldhave triggered the process detailed in the service orderfor a premises risk assessment. This process shouldhave also ensured that sandwich panel constructionwas detailed on the mobilising turnout sheet. All ofwhich was also seen as an area for improvement in theOperational Assessment of Service Delivery 2006 withregard to the passage of information betweenoperational crews and fire safety staff and vice versa.Additionally the assessment also criticised thepremises re-inspection programme where it wasidentified that a random selected premises containedhand written amendments that had not been added tothe central database, therefore some crews attendingthe site may not have possessed up to date riskinformation.

6.1.5 Recording training

It is unknown if all staff received training on thedelivery of service orders or any other writtencommunication as there was no evidence (records) toconfirm the delivery of this type of information toWFRS staff. The method of recording training in WFRSwas a computerised system called Redkite forWholetime firefighters. For retained duty system (RDS)staff it was largely a paper-based recording system.Neither system provided a means to ensure the qualityof delivery, underpinning knowledge gained andcompetence of WFRS firefighters. It was also identifiedthat there was no robust process for the recording oftraining for officers and assessment of continuedcompetence.

22

6.1.6 BA training

BA training requires a complete overhaul, includingidentified courses, syllabus content and courseduration. For example the initial BA course for RDSstaff had been reduced and does not comply withnational guidance. Also BA refresher training wassacrificed for the introduction of fire behaviour trainingthus no longer maintaining core skills. The BA refreshercourse must be reintroduced as per national guidanceand should be delivered as a separate entity to the firebehaviour course. Because of the introduction ofIntegrated Personal Development System (IPDS), theideal around this was for individuals to self nominatefor mandatory BA refresher courses. This obviouslyfailed as records identified that some staff had notcompleted BA refresher training for many years.

6.1.7 RDS database

The Operational Assessment of Service Delivery 2006also stated that the development and maintenance ofRDS staff differs significantly to that delivered towholetime personnel. It also identified that themonitoring, recording and auditing of training activityand assessments of RDS personnel was weak with nocentral database to demonstrate RDS workforcecompetence. However, during the investigation it wasfound that deficiencies in this area also extended towholetime personnel including officers.

6.1.8 Computer based training

Computer based training was the only method ofdelivering various functions including IncidentCommand, which occasionally was monitored duringexercises. This system does not provide a robustassessment of underpinning knowledge. Many WFRSfirefighters see it as a team event as opposed toindividual training and assessment.

6.1.9 Command Support

Command Support also forms an important functionwith the incident command system. As a result of this,that evening there were significant errors that affectedthe delivery of command support. In WFRS there islimited training delivered in command supportespecially in the completion of risk assessments,therefore there was no written evidence recorded of

risk assessments during the offensive operations of theincident. The command point had to be moved on anumber of occasions from the back of one applianceto another for various reasons with the firefightercarrying vehicle nominal roll and officer fobs in his firehelmet. Furthermore there was no sector commanderor dedicated crew identified for the additional supportfor command support as the incident progressed.

6.1.10 Appliances

The Control Unit had been off the run for aconsiderable time and no contingency plans had beenput in place meant that the BA Pod had to be used fortwo functions, Command Support and BAMC. Oneappliance carrying out two functions means that theremust be a competent and dedicated crew for eachfunction.

6.1.11 Monitoring

It has already been mentioned that the OperationalAssessment has identified areas for improvementregarding training of staff. Workplace assessments atincidents were also criticised with no evidence ofmonitoring staff performance.

6.2 General conclusions

6.2.1 Serious Accident Investigation process

The primary purpose of the FBU’s Serious AccidentInvestigation (SAI) process is to prevent the seriousinjury or death of firefighters at similar incidents in thefuture. This summary report highlights three broadareas:

l IRMP

l Incident Command and Control

l Use of and Command and Control of BreathingApparatus

6.2.2 IRMP

Every firefighter accepts that there exists an element ofrisk associated with the work that they are required to

23

undertake. However what comes with this expectationis a belief that their employer will have done everythingwithin their powers to minimise any potential andforeseeable risk that does exist by carrying out anexhaustive risk analysis, planning and resourcingexercise in the form of an IRMP. The section on IRMPabove highlights a number of inadequacies with theIRMP process undertaken by WFRS prior to and at thetime of this incident. These recommendations are notexhaustive and further reference should be made tothe full SAI report. The FBU believes that the issue ofIRMP is one that should not just be the subject of localscrutiny by WFRS alone, but that it should be an areathat government, employers and the HSE should take agreater interest in. There is a need for greater scrutinyin regard of the drafting, implementation and adequacyof IRMPs. It seems that too much emphasis is placedon the way the plans are drawn up and far too little onwhat they actually mean and what they are able todeliver in the form of an effective fire and rescueservice.

6.2.3 Incident Command and Control

Assuming that a fire and rescue service IRMP hasdetermined that a particular risk exists and that as afire and rescue service they have a duty to attendincidents at such a risk, it should go without sayingthat the service’s IRMP should indicate what theexpected outcome of that attendance should be. Inorder for this to be the case it is incumbent on the fireand rescue service to have undertaken the previouslymentioned risk analysis exercise in order to formulate aplan and to calculate necessary resources to facilitatethe expected outcome. Only by undertaking thisexercise can Incident Commanders decide uponfireground tactics and strategy and importantlywhether they have sufficient resources available at anytime throughout the duration of an incident to meetfire and rescue service expectations. With regard to thisparticular incident, the quality of information availableto the initial incident commander whilst en route andwhilst in attendance was inadequate, calling intoquestion not just the IRMP process, but also theoperational pre-incident planning process for thisparticular site. In essence this made effective incidentcommand an impossibility from the outset and theIncident Commanders and crews were effectively setup to fail.

6.2.4 Breathing Apparatus

The vast majority of on duty deaths involvingfirefighters take place whilst they are wearing BA. It isfrustrating that the FBU are too often required tocontribute in one form or another to proposals onguidance referring to the use of BA; a number of whichwe view as a dilution of current arrangements. It standsto reason that whilst current arrangements do notprevent the loss of firefighters whilst wearing BA, anyproposed guidance of a less stringent nature wouldlead to an increase in similar events. This would betotally unacceptable. This is why we have made anumber of recommendations that seek to improve theguidance employed in the use of, and control of, BA.Some of these recommendations are applicable toWFRS but equally other fire and rescue services woulddo well to carry out similar exercises. Some of therecommendations refer to issues which we feel wouldbe best dealt with nationally.

6.2.5 Other concerns

The three areas mentioned above do not form anexhaustive list of topics addressed within the full FBUSAI report, nor do they address all of our concerns inthe three particular areas themselves. However they doconstitute three key areas of concern where we believethe fire and rescue service is not learning from itsprevious mistakes. All too often when incidents suchas these are dissected, as they always are, do we drawcomparisons to other incidents. Until such time as allconcerned acknowledge this and make a concertedeffort to address the underlying issues, the FBUremains gravely concerned that similar tragic eventswill take place in the future.

The conclusions and recommendations are based onthe information, evidence and documentation that hasbeen made available to the FBU and to the best of ourknowledge was accurate at the time of producing thisreport. We emphasise that any additional informationsubsequently becoming available could alter thefindings of this and any future reports.

24

7) Recommendations

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

l National Framework

l Integrated Risk Management Plans (IRMP)

l Risk information

l Incident Command System

l Dynamic Risk Assessment

l Breathing Apparatus (BA)

l Water supplies

l Operations

l Fire development and firefighting actions

In this summary report, three key areas ofrecommendations have been extracted.

7.1 IRMP

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

7.1.2 Central government must introduce a robustprocess of scrutiny that demonstrates that a risk-basedapproach has been applied to the production of localIRMPs.

7.1.3 DCLG must issue a circular immediately toadvise that fire and rescue authorities must haveregard to Fire and Rescue Authorities – Health, safety andwelfare framework for the operational environment, publishedin June 2013, when developing their IRMP. The FBUshould ensure the same issue is raised elsewhere in theUK.

7.2 Incident Command

7.2.1 In 2007 the Warwickshire Fire and RescueService Incident Command System was operating toFire Service Manual, Volume 2, Fire Service Operations,Incident Command, second edition. The fire andrescue service must ensure the best possibleoperational intelligence is available en-route and at theincident ground from owners and managers of the site.

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

7.2.3 Warwickshire Fire and Rescue Service mustreview and update S.O. 01.02.21 Incident CommandSystem, in recognition of the importance ofcommunication on the incident ground. This mustinclude risk, task and deployment information. Thisshould be completed within twelve months.

7.2.4 Robust training must be provided in recognitionof the importance of communication on the incidentground. This must include risk, task and deploymentinformation to all firefighters and sector commanders.

7.2.5 At all incidents there is always an element ofrisk and the level of risk must always be balancedagainst what will be gained. To achieve this, anassessment of the risk must be carried out and thisprocess must continue at regular intervals throughoutthe incident. Warwickshire Fire and Rescue Servicecomputer-based training lecture package on CommandSupport details the function of gathering written riskassessments from the incident. Risk assessments mustbe recorded and risk information passed on toattending crews.

7.2.6 Warwickshire Fire and Rescue Service mustreview and update S.O. 01.02.21 Incident CommandSystem, in recognition of the importance of riskassessment and the introduction of any relevantcontrol measures on the incident ground and to reflectcurrent fire and rescue service national guidance andbest practice. This should be completed within twelvemonths.

25

7.2.7 Risk assessment is a management responsibilityand therefore must be carried out in line with theManagement of Health and Safety at Work Regulations1999 (MHSWR 1999) and undertaken by crew managersor above.

7.2.8 Robust training must be provided on carryingout a risk assessment on the incident ground to allcrew managers and above, and undertaken annually.

7.3 Breathing Apparatus

7.3.1 Agreement needs to be reached on thereplacement for TB 1-97. The new policy must ensureno reduction in the various safety measures andsafeguards contained within current guidance andshould, where possible, improve safety relatedsafeguards.

7.3.2 Whilst WFRS has in place Service Order05.04.10, a review/audit of this service order needs tobe implemented to ensure compliance with the fire andrescue service national guidance and best practise onselection of BA teams leaders and BA wearers. Itshould further ensure a robust process is in place todemonstrate that all firefighters and incidentcommanders have gained the underpinning knowledgeessential for ensuring that they can carry out theirfunctions safely.

7.3.3 A singular national system for the designation ofBA Entry Control Points and the numbering of BAteams should be adopted to remove confusion andimprove interoperability between fire and rescueservices. Such a system can only be guaranteed withthe introduction of robust training, policies andprocedures thus allowing firefighters and incidentcommanders to deliver on a consistent basis. Theattainment and maintenance of these skills should bevalidated on an annual basis in order to ensure theimplementation of ongoing safe systems of work.

7.3.4 Where BA wearers are to be re-committed, thensuch a commitment should be for a specific task onlyand must have due regard to the fitness of BA wearers.

It is crucial for officers in charge and all BA wearers torecognise the signs and symptoms of heat stress andother thermal-related health and performance issues orconditions i.e. experiencing dizziness, nausea,abdominal pain, or a burning sensation of the skin,illogical decision making, or other unusual cognitivebehaviour. The accurate recording of BA wearersnames; time of entry and exit, a brief description of theconditions and activity must also be recorded. In viewof the serious issues surrounding the re-committing toan incident of firefighters in BA, this issue should bekept under review by all stakeholder. Theseconsiderations should take account of developingknowledge regarding the physiological effects ofwearing BA in fire situations.

26

Notes

27

Notes

Fire Brigades UnionBradley House68 Coombe RoadKingston upon ThamesSurrey KT2 7AE

Tel: 020 8541 1765Fax: 020 8546 5187

www.fbu.org.uk