() () () () o \:J o o o. 'Report of the Brigade.Investigation. ',.'. lllto the Death of "..;"-.Firefighter Fleur Lonibard. cj ej.

Transcription

1 )!) :J () () () () () Cj o o o \:J o o o cj ej o U u U 'Report of the Brgade.nvestgaton ',.'. lllto the Death of "..;"-.Frefghter Fleur Lonbard

2 ) ) ) } ~ ) \) (J () (j (J () (:J (J () U \~ U u AVON FRE BRGADE REPORT OF THE BRGADE NVESTGATON NTO THE DEATH OF FREFGHTER FLEUR L01v1BARD on Sunday 4th February 1996 at Leo's Supermarket Broad Street Staple Hll Brstol Presented By the Brgade nvestgaton Team Chef Fre Offcer, Avon Fre Brgade. All rghts reserved. No part of ths publcaton may be reproduced, stored n a retreval system, or transmtted n any form or by any means electronc, mechancal, photocopyng, recordng or otherwse wthout the pror permsson of the Chef Fre Offcer. ()

3 PREFACE Ths Report has been compled for the Chef Fre Offcer of Avon Fre Brgade. t represents the unfettered fndngs, conclusons and recommendatons of the offcal Brgade nvestgaton Team followng our comprehensve nqures nto the fatal fre at Leos Supermarket, Staple Hll, Brstol on 4th February 1996, whch clamed the lfe of Frefghter Fleur Lombard. When the Terms of Reference for the nvestgaton were agreed, the then Chef Fre Offcer declared that the nvestgaton should be rgorous, searchng and open n ts approach and leave no stone unturned n the quest to fnd out all of the facts. n presentng our fndngs, we have been conscous of the contentment expressed by the Home Offce nspectorate, the Health and Safety Executve and the Fre Brgades Unon for ther own ntal nqures to be served by ths nvestgaton. n conductng the nvestgaton, we have addressed specfc ssues rased by the Health and Safety Executve whch are covered n the Report and at the same tme, attempted to harness and report on wder ssues whch we antcpated would be of partcular relevance to the Home Offce and the Fre Brgades Unon wthn the Terms of Reference lad down. We have been mndful that the Report may have attracted a wder crculaton amongst other nterest groups who may not be conversant wth the relevant polces, procedures and jargon applyng n some of the areas that we have nvestgated. The tenor of the Report has therefore attempted to descrbe the approprate practce or polcy prevalng where necessary and then detal our fndngs n that context. We have been constantly mpressed wth the unqualfed co-operaton and openness of wtnesses and others to whom we have spoken throughout the nvestgaton and we wsh to express our apprecaton for ther assstance and for the professonal and techncal expertse that we have drawn on from a wde range of organsatons and ndvduals. Wthout ther help, t would have been mpossble to comple ths Report. Sgnature Removed Sgnature Removed D W Hutchngs QFSM Grad LF.E Actng Deputy Chef Fre Offcer (Brgade nvestgaton Offcer) P G Shlton M..Fre.E Dvsonal Offcer (Assstant nvestgaton Offcer) September 23rd, 1996 ()

4 CONTENTS Secton 1 SUMMARY 2 NTRODUCTON 2.1 Sequence of Events 2.2 Purpose of ths Report 2.3 Polce nvestgaton 2.4 nvestgaton Strategy 2.5 Sources of Evdence 2.6 Terms of Reference 3 THE PREMSES NVOLVED 3.1 Buldng Hstory 3.2 Arrangement of Premses 3.3 Buldng Constructon 3.4 Roof and Celng Constructon 3.5 Meat Preparaton Room 3.6 Legslatve Fre Provsons 4 BRGADE ATTENDANCES 4.1 Applances Attendng 4.2 Personnel Attendng 5 NCDENT RECONSTRUCTON 5.1 Scenaro Before the Fre 5.2 Dscovery of the Fre 5.3 Ext Door 5.4 Speed of Events 5.5 Fre Brgade Actons 6 CAUSE OF FRE 6.1 Reportng Procedures 6.2 Seat of Fre 6.3 Conclusons about Cause of Fre Page CAUSE OF DEATH 7.1 Custody of Deceased 7.2 Postmortem Examnaton 7.3 Recorded Cause of Death 7.4 Evdental Factors FRE DEVELOPMENT 8.1 Background 8.2 Route of Fre Spread 8.3 Heat Output 8.4 Crucal Factors 8.5 Fbreboard Celng 8.6 Supposed 'Flashover' 8.7 Fatal Effects ()

5 9 GENERAL BREATHNG APPARATUS PROCEDURES Polcy Gudance Controllng Procedures Breathng Apparatus Emergency Use of Gudelnes BREATHNG APPARATUS NVESTGATON General mplementaton of Emergency Procedures Reportng Requrements Examnaton of Sets and Equpment Personal Protecton ssues 42 A Breathng Apparatus Sets 42 B Frefghtng Unform General Applcaton of Procedures Brefng Personal Lne Attachment Man Gude Lne BA Emergency - Offcer Responsbltes Preservaton of Breathng Apparatus Control Board Supervson of Casualty Breathng Apparatus Entry Control Procedures 10.7 T ranng and Competence Standards General Recrut Tranng Probatonary Tranng Statutory Tranng Routne Tranng Specalst Tranng Core Progressonal Tranng Tranng n the Phenomenon of Flashovers Rsk Famlarsaton 11 PERSONAL PROFLE - FLEUR LOMBARD Status Educatonal Qualfcatons Professonal Qualfcatons Prevous Employment Lesure Actvtes CONCLUSONS AND RECOMMENDATONS General Personnel Breathng Apparatus Procedures Command and Control Tranng Fre Safety 63 ACKNOWLEDGEMENTS 66 SUMMARY OF RECOMMENDA nons 67 (v)

6 APPENDCES la (a)() 5 (a) (2) 5 (a) (J) 5 (a) (4) 5 (a\s) 5 (b) 5 (c) 5 (d) 5 (e) 6 7 ncdent Events Chart Ff 9 Statement FRS Cone Calormeter Test Results Dutes of Entry Control Offcers - Stage 1 ncdent nvolvng Wearer Dstress - O&T BA Set 359 Backpate Assembly and Cylnder Report BA Set 359 Facemask and Ancllary Equpment Report BA Set 359 BA Set 359 BA Set 359 Sketch Plan of Locaton of Recovered Breathng Apparatus Set remans Report of Examnaton of mpounded Breathng Apparatus Set No 359 Report of Examnaton of mpounded Breathng Apparatus Set No 363 Letter - North Safety products - 8th February 1996 Scentfc Servces Report on Breathng Apparatus Test Samples - 12th Aprl 1996 Dagrammatc Reconstructon of Breathng Apparatus Control Board - (Pages 1-16) - (Page 17 of above) - (Pages 1-10) - (Pages 1-3) - (Pages 1-2) - (Page 1) - (Page 2) - (Page 3) - (Page 4) - (Page 5) - (Page 1) - (Pages 1-6) - (Pages 1-7) - (Page 1) - (Pages 1-2) - (Page 1) No TABLES Scentfc Servces Test Results of Breathng Apparatus Samples Personal Protecton Equpment Worn by Frefghter Lombard Forensc Test Results of Samples from Frefghter Lombard Forensc Test Results of Samples from Frefghter 9 Probatonary Tranng Scheme Key Result Credt Avalablty Synopss of Tranng Receved Page (v)

7 116 1 Summary 1.1 On Sunday, 4 February 1996, a fre occurred at Leo's Supermarket at Staple Hll, Brstol n whch Frefghter Fleur Lombard, whlst nsde the premses wearng breathng apparatus lost her lfe. The fre, the supposed cause of whch s recorded as delberate gnton, ravaged through the buldng at about lunchtme whlst the shop was open for tradng. Frefghtng and dampng down operatons contnued at the premses untl the ncdent was fnally closed at about 1800 hours on Thursday, 8 February mmedately t became known that Frefghter Lombard was mssng, a full Breathng Apparatus Emergency was nstgated whch quckly located the deceased frefghter who was recovered and passed to the care of ambulance paramedcs. 1.3 All breathng apparatus and ancllary equpment n use by the breathng apparatus team of whch Frefghter Lombard was a member was mpounded and the locaton from whch the deceased was recovered was also secured ntact for later nvestgaton. 1.4 The Chef Fre Offcer ordered a full nqury nto the ncdent, the detals of whch are the subject of ths Report. The enqures that have been made nto the ncdent have been conducted by a small nternal nvestgaton Team headed by the Assstant Chef Fre Offcer (Operatons) (the Actng Deputy Chef Fre Offcer at the tme of wrtng ths Report). 1.5 By agreement wth other nterested groups, t was decded at the outset that all enqures of personnel relatng to the ncdent would be handled exclusvely by the nvestgaton Team to mnmse the effects of post traumatc stress on the wtnesses concerned and to ensure that the evdence collated was properly controlled and coordnated n the nterests of establshng exactly what happened. Ths approach to the nvestgaton was accepted by the Home Offce, the Health and Safety Executve and the Fre Brgade's Unon to whom ths full ncdent nvestgaton Report s ntally drected. 1.6 The separate fre nvestgaton nto the cause of fre has concluded that the fre was started delberately n a stock of polystyrene packagng materals wthn the meat preparaton area of the supermarket and at the tme of preparng ths Report, the contracted securty guard on duty n the supermarket at the tme s remanded n custody charged wth the unlawful kllng of Fleur Lombard and wth two charges of arson; one related to the ncdent at Leo's and another some days prevously at a chldrens superstore where he was workng at that tme. 1.7 The enqures made to nvestgate the ncdent have extended beyond ntervewng the Brgade personnel n attendance at the relevant tme. The nvestgaton has taken account of Polce statements (to whch the nvestgaton Team were afforded confdental access) photographs and vdeo tapes from a number of sources, forensc evdence, scentfc test results, fre behavour specfcatons and data together wth test data and other evdence from the Fre Research Staton of the Buldng Research Establshment. Such evdence has allowed the fre scenaro to be reconstructed wth a hgh degree of accuracy whch has led to the concluson that Frefghter Lombard ded as a result of the effects of a massve flashover whch generated temperatures n excess of 100Q C. 1.8 n addton to establshng the crcumstances surroundng Frefghter Lombard's death, the nvestgaton focused on the effects of the buldng constructon and the buldng materals together wth the freloadng wthn the supermarket n an endeavour to dentfy any contrbutory factors affectng the behavour of the fre. n ths respect, comments are made n the Report concernng the use of fbreboard celng panels and about the vared roof ptches and vod capactes n a buldng whch had been ncreased n sze over many years by extensons and nterconnectons to c;eate a growng retal sales area. Recommendatons are made about the re-consderaton of Buldng Regulatons standards n respect of the provson of sprnklers n occupances of ths type. 1.9 Durng the course of the nvestgaton, consderable attenton was pad to the practces and procedures adopted n respect of command and control, practcal frefghtng technques and breathng apparatus procedures to establsh essentally f any were so sgnfcantly flawed as to have had a drect bearng on the tragc death that occurred and also to determne f lessons could be learned whch would cause changes to be recommended to exstng procedures. t wll be somewhat re-assurng for the Brgade to know that the nvestgaton Team concluded that although some omssons or defectve practces were revealed about whch recommendatons are made, none are consdered to have been drectly assocated as a contrbutory factor to the death of Fleur Lombard. The rapd development of fre n ths ncdent can only be descrbed as a hghly unusual phenomena whch consumed n ts progress, an extremely unfortunate vctm whch was unpredctable and unavodable gven the professonal command and control tactcs adopted A number of recommendatons are made as a drect consequence of the nvestgaton and these are commended to the approprate authortes for serous consderaton. Page 1

8 116 2 ntroducton 2.1 Summary of Events At 1246 hours on Sunday 4 February 1996 a 999 call was receved at Avon Fre Brgade Control reportng a fre at Leo's Supermarket, Broad Street, Staple Hll, Brstol. A further 24 repeat calls to the same ncdent were recorded, the last tmed at 1423 hours the same day. An jntal at:tendance of two pumps was moblsed to the premses, reportng n attendance at 1251 and 1252 hours respectvely. At 1253 hours a message was transmtted va the Brgade rado scheme from one of the applances n attendance requestng pumps to be 'made four'. The two addtonal pumps moblsed to the ncdent n response to the make-up booked n attendance at 1257 and 1302 hours respectvely. Further 'make-up' messages were sent at 1311 hours (to 6 pumps and hydraulc platform), and 1343 hours (to 10 pumps). The stop'message was sent at 1643 hours detalng '10jets n use, 1 aeral montor, 8 breathng apparatus, 2 casualtes removed, 1 severely, relef crews detaned some tme'. After a gradual scalng down of frefghtng operatons and perodc nspectons of the premses, the ncdent was fnally closed at 1804 hours on Thursday 8 February The frst and second crews n attendance mmedately engaged n frefghtng operatons from the car park at the rear of the buldng, eventually makng an entry nsde the buldng by breathng apparatus wearers through a fre ext doorway desgnated Entry Control Pont 1 (ECP1). The thrd and fourth crews to arrve at the ncdent formed between them, a team of four breathng apparatus wearers whose task was to make an entry nto the heavly smoke-logged buldng through a second entry pont whch was the man customer entrance to the supermarket and desgnated Entry Control Pont 2 (ECP2). The four breathng apparatus wearers entered the buldng at 1306 hours, one par equpped wth sonc rado communcatons who were nstructed to lay a gudelne, and the other par wthout sonc rado communcatons carryng a hgh pressure hosereel The two teams became separated almost mmedately they entered the buldng and proceeded wth ther respectve tasks n dfferent drectons at about 90 to each other. The team who entered wth the hosereel (Team 2) were nsde the buldng for only about three mnutes when they began to retreat due to deteroratng condtons as the heat ntensfed and became unbearable. The gudelne team (Team 1) meanwhle proceeded wth ther task of layng the gudelne. At about the same tme that Team 2 returned to the breathng apparatus Entry Control Pont (ECP2), Team 1 had also decded to retreat havng agreed that they could not stay n much longer due to the condtons. At about the same tme, Frefghter Lombard, the Team Leader of Team 1 shouted; 'Evacuate, evacuate', presumed to be precptated by hearng the order to evacuate on the sonc communcatons rado from the breathng apparatus Entry Control Offcer t was whlst Team 1 were evacuatng that a massve flashover occurred causng the two team members to become parted. The sudden mpact of the flashover, beleved to be the effects of a blast, threw Frefghter 9 the second member of Team 1 away from hs team-mate, Frefghter Fleur Lombard and onto the floor some 3 to 4 metres away, at the same tme causng hm to momentarly black out. As he reganed hs orentaton, Frefghter 9 was spotted standng up just nsde the man entrance lobby by another Frefghter standng nearby who went to hs ad and asssted hm towards the man entrance doorway Frefghter 9 unaware of the tme lapse or of the crcumstances, mmedately sought to establsh f hs colleague Fleur had come out. On hearng that she had not, he nstnctvely grabbed a hosereel from another Frefghter standng nearby and returned nto the fre to search for her. He was followed, by another Frefghter who was also n the lobby area rgged n breathng apparatus. They located Frefghter Lombard very quckly just nsde and to the left of the man entrance from where they both recovered her deceased remans The death of Frefghter Fleur Lombard prompted a number of ntatves wthn the Brgade to satsfy not only compulsory reportng procedures but also to answer the crucal questons about how and why such a tragedy should have occurred at all. 2.2 Purpose of ths Report On Monday, 5 February 1996 after consultng wth hs Prncpal Offcer colleagues, and Her Majesty's nspector of Fre Servces, HM 1 CBE Ost] QFSM GFreE MSM, the then Chef Fre Offcer, 1 MFreE, FnstM AMSM determned that a full nvestgaton should be launched nto the death of Frefghter Fleur Lombard He mmedately apponted Assstant Chef Offcer D Hutchngs, QFSM Grad.F.E. (Actng Deputy Chef Fre Offcer at the tme of preparng ths Report) as the Brgade nvestgaton Offcer and Dvsonal Offcer P G Shlton, MFreE to assst hm wth the nvestgaton The ncdent gave rse to the need for the followng reports to be collated by the Brgade. Page 2

9 ntroducton (a) (b) (c) (d) (e) (f) Form FDR1 - Report of Fre (Home Offce) Form F Report of njury Dsease or Dangerous Occurrence (RDDOR) (HSE) Fre nvestgaton Report (Home Offce) Coroner's Report (on determnaton of H.M. Coroner) Unusual or Specal nterest Report (Home Offce) ncdent nvestgaton Report (nternal) Ths Report represents the ncdent nvestgaton Report, ((f) above), whch as stated n paragraph 1.5, s also ntended to address the requrements of the Home Offce, the Health and Safety Executve and the Fre Brgade's Unon to whom copes of the Report have been made avalable. The drect concerns of these groups were taken nto account durng the course of the nvestgaton and have been addressed n ths Report The Report therefore seeks to detal the full crcumstances of the ncdent together wth the actons and procedures that were followed n accordance wth the Terms of Reference lad down (see paragraph 2.5). 2.3 Polce nvestgaton Consstent wth the crcumstances of the death at ths ncdent, the Polce had a statutory duty to nvestgate whether the death occurred as a result of unlawful acts. Ther own nvestgaton was closely co-ordnated wth that of the Brgade and nformaton was openly shared between the two servces whch mnmsed a duplcaton of effort and also reduced as far as possble, the traumatc effects of gvng evdence, partcularly n respect of the Brgade personnel drectly nvolved wth the fatalty. The ntal Polce enqures ultmately changed to a crmnal nvestgaton culmnatng n charges beng preferred n respect of the unlawful kllng offleur Lombard and of two separate charges of arson, one of whch related to the fatal ncdent at Leo's and the other concernng a fre n the publc tolets at Chldren's World, Brstol on the prevous weekend Trbute s pad by the nvestgaton Team to the Polce Offcers, Forensc Scentsts and Scenes of Crme Offcers concerned wth ths ncdent for ther outstandng co-operaton wth the Brgade nvestgaton whch at all tmes, was avalable wthout queston, condton or qualfcaton. The nherent confdentalty of the Polce nvestgaton was respected throughout and wth a mutual regard for the nterests of each servce, the purpose of the respectve nvestgatons was always kept foremost to the eventual beneft of both servces' objectves. 2.4 nvestgaton Strategy n the lght of the traumatc effecrs the loss of a Brgade colleague would have on other personnel, partcularly those closely nvolved wth the ncdent at the crtcal tme, the nvestgaton strategy was ntended to respect the grevng process of close colleagues and at the same tme, mnmse any addtonal trauma whch could result from ntervewng and cross-examnaton of wtnesses. For these reasons, and because the Polce had a duty to fulfl n ntervewng wtnesses, t was agreed between the Brgade and the Senor Polce Offcer that the Brgade nvestgaton Team would be present durng ntervews and statements from Brgade members. Copes of these statements together wth those taken from supermarket employees, shop customers and members of the publc were made avalable to the nvestgaton Team whch asssted greatly wth the nqures n addton to wtness statements, t was deemed necessary as a crucal element of the nvestgaton, to reconstruct as far as possble, the events surroundng the death on a mnute by mnute bass over the crucal tmeframe. The complexty of evdence from the wde dvergence of sources gave rse to an 'ncdent Events Chart' beng devsed whch forms Appendx 1 of ths Report. The chart plots the progress of a varety of relevant events and actons n one mnute tmeframes from 1243 hours to 1330 hours. The events were plotted from a wde range of evdence ncludng statements, ntervews, ncdent log detals, known breathng apparatus events as well as photographc and vdeotape recordngs. n an attempt to acheve as hgh a degree of accuracy as possble n the tmng of partcular events, the detals have been corroborated as much as possble by alternatve sources of evdence and nformaton. The nvestgaton Team therefore have a hgh level of confdence n the accuracy of the reconstructed events. 2.5 Sources of Evdence Durng the course of the nvestgaton, evdence was collated from the followng sources: (a) 21 statements from Brgade personnel (b) 22 ntervews of Brgade personnel (c) 4 Polce statements of supermarket employees (d) 1 Polce statement of supermarket securty guard (e) 10 Polce statements of supermarket customers (f) 2 Polce statements of ambulance paramedcs (g) 1 Polce statement of Polce Constable n attendance (h) 17 Photographs by member of publc durng fre () 111 Polce photographs after the fre G) 24 Polce photographs of deceased body (k) 55 Buldng Research Establshment photographs after the fre 0) 5 Brgade photographs of breathng apparatus set remams (m) 1 Statement of Forensc Scentst (n) 92 Brgade photographs after the fre (0) Fre Research Staton Report (P) Postmortem Report (q) Brstol Cty Councl Scentfc Servces Report (r) North Safety Products (Sebe Gorman) Report (s) Brstol Unforms Lmted Report (t) Brtsh Standard BS EN 366: 1993 Protectve Clothng - Protecton aganst heat and fre Page 3

10 ntroducton (u) (v) (w) (x) (y) (z) Brtsh Standard BS 5438: 1989 BS Methods of Test for Flammablty of textle fabrcs etc Techncal Bulletn 1/89 - (Brgade 0 & T Note A24) Brgade Moblsng and ncdent Log detals Brgade breathng apparatus nvestgaton Report Brgade Report nto Cause of Fre 3 Vdeo tapes from varous sources 2.6 Terms of Reference The Terms of Reference for the ncdent nvestgaton of whch ths document s the Report were agreed by the Chef Fre Offcer as follows: To establsh the crcumstances surroundng the death of Frefghter Fleur Lombard. To dentfy all or any contrbutory factors affectng the behavour of the fre whch may requre acton or further nvestgaton. To dentfy any'brgade practces or procedures whch may need to be revewed. To make recommendatons wth regard to the mplementaton of any fndngs n the above categores. Page 4

11 3 The Premses nvolved 3.1 Buldng Hstory The buldng's orgns date back to about 1900 when terraced houses were bult on the ste. n the md- 1960's, these were acqured and converted nto a small department type store. Co-operatve Retal Servces (CRS), the leaseholder of the premses at the tme of the fre, further converted the buldng to a supermarket n 1972 and as a consequence, a Fre Certfcate was ssued by Gloucestershre Fre Servce n 1973 under the requrements of the Offces, Shops and Ralway Premses Act (Gloucestershre Fre Servce was the fre authorty for the area pror to Local Government Reorgansaton n 1974). constructon. The premses were dvded nto three occupances, the largest on the ground floor beng occuped by Leo's as a Supermarket and extendng to approxmately metres. Also on the ground floor but separated from Leo's as a separate occupancy was an area of about metres occuped by Clfton and Harrs as a carpet and furnture retaler on the north-west corner of the buldng. The frst floor sectons of the premses were about metres whch were nterconnected as one premse but were arranged n a random fashon above part of the furnture and carpet retaler and part of the Supermarket. The occuper was Kngswood Labour Club operatng as a lcensed club regstered under the Lcensng Act 1964 and n possesson of a Club Regstraton Certfcate. ) o 3.2 Arrangement of Premses The premse was a hybrd of a range of former buldngs whch had been extensvely converted, nterconnected, extended and re-roofed to form the Leo's Supermarket t was at the tme of the fre. t occuped an 'L' shaped ste of approxmately 60 metres x 40 metres maj{lmum and was of part sngle and part two storey "" ".... "',, -. ' " :;...,'0- ':':":... :. 3.3 Buldng Constructon The buldng constructon was manly of sold 'brck-and-a-half' walls, some rendered but wth ndvdual parts utlsng a varety of materals and constructon methods consstent wth a buldng whch had been the subject of several alteratons and addtons over the years. The ground floor was concrete and the frst floor tmber Plate 3.. :., :; ", p,,:j Page 5

12 ~lt)cle' ~ 1J~ lsllll ~CES CE CES S g:pllal[ OCOJ'ER fl.1nllj((oolel RtlAlll{A flallj(( SCJl[D GRru{) FL OOR Fgure 1: Ground Floor Plan Page 6

13 r>j C(),'R(SS(R 8 1V PtEW C(),'R(SS(R ROCJj ROCJj SCllE VOD VOD FRST HoeR AND ROOF Fgure 2: Frst F/oO)" Plan Page 7

14 The Premses nvolved ) ) ) ) J J Plate 4 boarded on tmber josts wth parts of the frst floor above the retal area supported on RSJ's. The faca on the Byron Place elevaton was clad n decoratve alumnum faca panels. 3.4 Roof and Celng Constructon areas wth the excepton of the asle mmedately n front of checkout No 1 (dsplayng wnes, sprts, beers, soft drnks, snacks and bread). Ths asle was sgnfcant as the one n whch the deceased was found, and was part of the two storey area beneath the Labour Club above. The tmber josted floor constructon of the club room caused the celng level n that part of the supermarket below to be Plate 5: llustratng lower celng heght below Labour Club As a consequence of the ongong expanson of the premses, the roofng was a conglomeraton of about ten ndvdual roofng structures, each havng apparently covered ndvdual premses before ntegraton nto the CRS complex of buldngs. About half of the roof structures were ptched, some of whch were tled and some covered wth corrugated asbestos cement sheetng but all wth dfferent ptches, dfferent heghts and wdths and wth some of the apex's runnng at 90 to each other. The other half of the roof structures were flat of tradtonal strammt board constructon, weather sealed wth btumen felt coverng or smlar weather proofng materals and agan of varyng roof lnes The sngle storey sectons of the premses occuped by Leo's had a common suspended celng lnng of standard heght throughout the retal and warehousng Page 8

15 HAND WASH WTH ElECTR C HEATER OYER SNK WTH BOXES Of ABSORBENT PADS :J1 ~. ~ ~ >.:J 8 ;os ~ ~ '" o ;os ~?t " ~ ~ c 'c;-, ~ ().....g' '""0 ~ U 0 ~... (1) '" ELECTRC DSPOSAL UNT UNDER POl YSTYR[NE TRAYS rl, MEAT eyo~ PREP. ROOM 2.5m Hgh Free-Standng Dsplay Fxture MEAT CHLL f;jy NDOW SPRTS Open Doorway f SNK WTH ELECTRC HEATER OYER FRU A~D V G COMPREpSOR ROOM '-0

16 The Premses nvolved some 0.2 metres lower than that of the suspended celng n the remander of the store. The undersde of ths celng was fnshed n skmned plasterboard wth a panted fnsh. The change of celng heght n ths area may have been a sgnfcant factor whch s referred to later n the Report Constructon of the tled roofed areas was of tradtonal close coupled roof desgn of varyng ptches and heght lnes. The flat roofs were tmber decked and weather sealed wth btumenzed roofng felt n the man wth one smaller area of flat roof havng been asphalted. The corrugated asbestos cement roofs were supported on trussed structures of tubular steel constructon nterlaced wth tmber and galvansed steel grddng whch supported steel hangars for the secondary grd whch accommodated the suspended celng panels. The retal shop area (except the area under the dub room descrbed n the prevous paragraph) had a celng of suspended fbre nsulatng board n decoratvely fnshed panels of 2.4 x 1.2 metres wth small tmber battens attached to the undersde to create the effect of smaller panels. The suspended celng n the warehouse area was of a slghtly dfferent desgn of hanger but also of fbre nsulatng board panels measurng 0.6 x 0.6 metres suspended on a steel grd. Ventlaton to the buldng was provded by arbrcks n the external walls mmedately below false celng heght t s a sgnfcant factor that the vods above the suspended celngs throughout the Leo's occupancy were contnuous thereby creatng vod capactes of varyng volumes and dmensons accordng to the type of roof above. There were no ntended cavty barrers wthn the roof vods and any barrers that dd exst were there fortutously as a gable end or upstand to one of the roof structures. n any event these were not mpervous and there was no evdence that any such barrers performed wth ether fre or smoke stoppng propertes t s also a sgnfcant factor that no cavty barrer or fre resstant separaton exsted between the retal shop area and the warehouse. These factors are referred to agan later n the Report. 3.5 Meat Preparaton Room The meat preparaton room measurng about 13 x 7 metres was constructed wthn the warehouse area from where t was accessed through unsecured sldng doors and had nstalled wthn t, three walk-n refrgerated cabnets used for the storage of meat and dary products. One of these however, was redundant and used as a dry store, manly for packagng materals assocated wth the packagng and dsplay of fresh meat products. For hygene reasons, the nternal walls of the room were constructed of melamne faced chpboard whch formed the partton walls wth the warehouse on two sdes. The partton wth the retal area had at one tme gven access to a delcatessen counter and dsplay area whch at the tme of the fre was ds-used. The former delcatessen was nterconnected to the meat preparaton room by a doorway for drect access purposes and a 2 metre wndow for vson nto the retal area. At the tme of the fre, the former delcatessen had been replaced wth a dsplay fxture contammg confectonary and nuts whch had been so postoned as to leave a space of about one metre behnd the fxture whch also enclosed the orgnal wndow and doorway from the meat preparaton room. (See fgure 3). The space thereby created by ths re-arrangement was used as a storage area for boxed packets of crsps and other savoury snacks The absence of fre separaton between these two areas coupled wth the hgh fre loadng represented by the storage of crsps was another sgnfcant factor whch s referred to later n the Report Also sgnfcant about the meat preparaton room was the storage wthn that compartment of other packagng materals. Wthn the mmedate vcnty of the packagng area were stored boxes of polystyrene food trays, packages of polythene/cotton wool absorbent pads on whch raw meat was presented, and quanttes of paper labellng and shrnk-wrap clear flm. These hghly combustble materals are consdered to have been the tem(s) frst gnted whch because of ther hgh calorfc value, had a crucal effect on the ntal development of the fre. These aspects are referred to later n the Report. 3.6 Legslatve Fre Provsons As prevously stated n Paragraph above, the premses were ssued wth a Fre Certfcate n 1973 n accordance wth Secton 29 of the Offces, Shops and Ralway Premses Act 1963 and the Offces, Shops and Ralway Premses Act 1963 (Modfcaton of Secton 29) Regulatons Secton 29 of the Act requred a Fre Certfcate to be appled for n premses where: (a) (b) (e) more than twenty persons were employed to work at anyone tme n any premses to whch the Act appled (as t dd n the case 0/ Leo '5); more than ten persons were employed elsewhere than on the ground floor 0/ any slch prem ses, or; any person was employed to work n any such prem ses n or under whch explosve or hgb/y flammable materals (0/ a prescrbed knd) were used or stored (n prescrbed quanttes) The Fre Certfcate was appled for on 9 November 1972 as a consequence of whch the, Gloucestershre Fre Servce (beng the Fre Authorty for the area at that tme) carred out an nspecton of the premses n accordance wth Secton 29(3) of the Act and subsequently ssued the Fre Certfcate on 1 May A Fre Certfcate ssued under Secton 29 of the OSRP Act was requred to detal the followng nformaton: Page 10

17 The Premses nvolved (a) (b) (c) specfy the greatest number of persons who n the opnon of the Fre A uthorty, could safely be employed to work n the premses; specfy precsely and n detal, the means of escape provded and state whch of them were to be treated as relevant for the purposes of the followng provsons of the Act relatng to the markng of exts affordng or gvng access to means of escape; state n the opnon of the Fre A uthorty f there exsted n the premses, any specal rsks of the outbreak or spread of fre and specfy those rsks The ssue of a Fre Certfcate under Secton 29 also mposed on an occuper certan other responsbltes specfed n the Act ncludng: or structural alteratons' to the premses or to the 'numbers of people employed' n the buldng, or to the 'materals stored or used theren'. Although several nternal alteratons were carred out n subsequent years wth full consultaton and ultmate approval of the fre authorty, none were so 'materal' as to warrant the applcaton of the Fre Precauton's Act justfed Sgnfcant alteratons were proposed n 1972, (stll under the jursdcton of the OSRP Act), and as a consequence, fre preventon recommendatons were made whch, when mplemented as part of the alteratons, resulted n the ssue of the Secton 29 Fre Certfcate on 1 May The fonowng observatons of the Fre Authorty were ncluded n that schedule of recommendatlons: (a) (b) the need to mantan and keep free from obstructon, the means of escape specfed (Secton 30(1)); the need to notfy the Fre A ttthorty of any proposals to make materal extensons or structural alteratons to the premses or n the numbers employed or the materals stored or used (Secton 30(2)); (a) (b) "MEANS OF ESCAPE Door from the ktchen area, and the door from the lobby should always be unlocked whlst persons are on the premses"; "GENERAL (c) (d) (e) (f) the need to ensure that ext routes and doorways should not be locked or fastened whlst people were at work (Secton 33(1)); arrangements of room contents so as not to mpede exts from the buldng (Secton 33(2)); specfed exts to be marked as such (Secton 33(3)); the need to provde e/foctve means of gvng warnng n case of fre and of testng and mantanng such fre alarms (Secton 34); (c) All wall and celng lnngs should be of ncombustble materal or of a materal havng not less than Class 1 'Surface Spread of Flame' ratng 'when tested n accordance wth Brtsh Standard Specfcaton 476: Part 1: 1953;" "n vew of the sze of the buldng, thought should be gven to the nstallaton of an automatc sprnkler system, whch should be n strct complance wth the Fre Offces Commttee Rules for Automatc Sprnkler nstallatons together wth the approprate amendments. " (g) (h) the need to famlarse employees wth the means of escape provded and the routne to be followed n case of fre (Secton 36(1)); a requrement to provde and mantan approprate means of fghtng a fre (Secton 38(1)); The relevance of the above three recommendatons S reconsdered n a later secton of the Report The Secton 29 OSRA Certfcate ssued n 1973 remaned n force at the tme of the fre n some twenty three years later. The Fre Precautons Act 1971 dd not ntally desgnate such premses and ths remaned the case untl 1976 when the Health and Safety at Work Etc Act 1974, ntroduced legslaton to make regulatons encompassng those new premses formerly wthn the scope of OSRA to brng them wthn the requrements of the Fre Precautons Act No retrospectve powers were ntroduced by ether Act to mpose.any of the new certfcaton requrements on premses already n possesson of an OSRA Certfcate. The new requrements could however have been appled to a premse wth an exstng Certfcate f, as outlned n paragraph (b) above, proposals were made to make 'materal extensons Page 11

18 4 Brgade Attendances 4.1 Applances Attendng The followng applances and personnel attended the ncdent both as part of the pre-determned attendance (PDA) and as a consequence of the message to 'make pumps Jour'. The other applances and personnel who attended the ncdent after 1330 hours are rrelevant to the nvestgaton and have not therefore been separately dentfed. Tme of Call hours. PDA: 2 pumpng applances Staton B7 Kngswood (1 pump) Staton B6 Speedwell (1 pump) Desgnaton and Moblsng Tmes of Frst Four Applances Attendng C) Applance Abbrevatons Staton Call Sgn Water Tender Ladder WrL B7 Bravo 72 Water Tender WrT B6 Bravo 61 Water Tender Ladder WrL B6 Bravo 62 Water Tender WrT Al Alpha 13 Tme Tme n Moblsed Attendance 12:47 12:52 12:47 12:51 12:54 12:57 12:55 13:02 Plate 6: (rght to left) B72, B62, A 13 J J u u u Page 12

19 Brgade Attendances 4.2 Personnel Attendng Water Tender Ladder (WrL) - B6 - (Bravo 62) Water Tender (Wrt) - B6 (Bravo 61) Sub Offcer Frefghter Frefghter Frefghter Offcer-n-Charge Drver/BAECO Breathng Apparatus Breathng Apparatus Staton Offcer 1 Frefghter 8 Frefghter 9 Frefghter F Lombard Frefghter 10 Offcer-n-Charge Drver Breathng Apparatus Breathng Apparatus BAECO (Detached from Cl) n attendance at 1251 hours Water Tender Ladder (WrL) - B7 - (Bravo 72) Sub Offcer Frefghter Frefghter Frefghter Frefghter n attendance at 1252 hours. Offcer-n-Charge Drver Breathng Apparatus Breathng Apparatus BAECO (Detached from A2) n attendance at 1257 hours Water Tender (WrT) - A1 (Alpha 13) Leadng Frefghter Frefghter 11 Frefghter 12 Frefghter 13 Frefghter 14 1 n attendance at 1302 hours Offcer-n-Charge Drver Breathng Apparatus Breathng Apparatus BAECO Page 13

20 5 ncdent Reconstructon 5.1 Scenaro Before the Fre Leo's traded as a general grocery supermarket and n lne wth ts compettors, was open to the publc on Sundays between 1000 and 1600 hours. On Sunday, 4 February 1996, there were three members of staff on duty n the supermarket together wth a securty guard who was employed by a local securty company under contract to Leo's. t was the practce at Leo's that full-tme sectonal supervsors/managers would act as duty store manager on those occasons when the supermarket general manager was not avalable. On ths occason, the duty manager for the day was nomnated as Mem Pub 1 the Warehouse Manager who began hs days work at about 0800 hours. There were several dutes for hm to undertake before the supermarket could open to the publc n whch he was engaged untl the frst member of staff arrved. Ths was an 18 year old student by the name of Mem Pub 2 who had worked as a part-tme checkout operator at the store on a SundaYemornng between 0930 and 1400 hours snce 15 October t was the custom for Mem Pub 2 to arrve at 0930 hours to assst wth the preparaton of the Sunday newspapers whch she dd on ths occason and was admtted to the store through the warehouse entrance from the rear car park by Mem Pub 1 After helpng nsert supplements nto the newspapers, Mem Pub 2 prepared her checkout tll for openng tme. The second member of staff was a Mem Pub 3 a freelance desgner who also worked part-tme at Leo's, a job she had occuped for the prevous eght years. For the prevous fourteen months, her part-tme shfts had been from 1800 to 2000 hours on Wednesdays and 1000 untl 1600 hours on Sundays. On 4th February, she arrved at about 0955 hours and was admtted through the man customer entrance doors on Byron Place bymem Pub 1 who at the same tme, opened the doors for customers. As Mem Pub 3 entered the shop, she was followed n by about eght customers who had been watng outsde for the shop to open. After changng nto her overalls n the staff room, Mem Pub 3 reported to checkout number four (numbered one to sx from the man entrance doors) (see Fgure 1) and was gven her tll key by Mem Pub 2 to enable her to start recevng customers. Whlst checkng out some of the frst customers, Mem Pub 3 became aware of a securty guard standng close to the checkout area whom she had never seen before The securty guard had worked for a securty company known as Securty, for the' prevous two and a half weeks. He was 20 year old Mem Pub 4 who had also been employed as a securty guard wth another company for the prevous year. t was hs frst tme on duty at Leo's and he reported to the duty manager at about 1000 hours or just afterwards. The duty manager, Mem Pub 1 was workng n the 'kosk' from where cgarettes, newspapers and lottery tckets could be purchased. Ths was the normal duty for the duty manager and at the tme that the securty guard arrved, Mem Pub 1 was qute busy servng customers some of whom had only come nto the shop to buy newspapers because a half-prce offer _ was avalable on that day. Mem Pub 1 acknowledged the arrval of the securty guard and dd not have tme to show hm around the store but gave hm permsson to use the telephone to book on duty wth hs employer. The securty guard then took up hs poston n the entrance foyer between the kosk and the checkouts. Mem Pub 1 dd not fnd tme to show the securty guard around the store at all thereafter Durng the course of the mornng, a steady trckle of customers passed through; at tmes farly busy and at other tmes somewhat slack. n the man, Mem Pub 1 spent most of hs tme n the kosk servng customers, although he dd leave t for short perods on a number of occasons ether to make hmself tea n the staff canteen or to go nto the warehouse at the back of the store to collect tems for customers. Untl about md-day, both checkout operators remaned at ther tlls throughout apart from bref occasons when they sorted out shoppng baskets or went to the kosk to collect carrer bags. The securty guard was seen to wander around the store perodcally and because of the restrcted feld of vson from both the checkouts and the kosk, he was not always n vew by members of staff. He had on occasons asssted Mem Pub 1 wth packng shoppng and wth the magazne returns and at one tme around 1100 hours, he had been asked by Mem Pub 1 to keep an eye on two or three young lads who had entered the store unaccompaned and aroused the suspcon of the duty manager. The lads eventually left the store wthout ncdent havng made a purchase through checkout number two operated by Mem Pub 2. At the tme that Mem Pub 1 alerted the securty guard, he was located n the managers offce adjacent to the staffroom allegedly makng a phone call to arrange a lft home. 5.2 Dscovery of the Fre As tradng slackened off just after md-day, Mem Pub 1 asked Mem Pub 3 f she wshed to take an early lunch break nstead of her normal tme of 1300 hours. She declned hs offer but suggested that he take an early lunch hmself whlst she stood n for hm n the kosk. Mem Pub 1 agreed to ths and after cashng a personal cheque for hmself at the kosk, he walked around the store gettng hs own shoppng. Mem Pub 3 checked out hs shoppng at the kosk where he pad for t. The securty guard asssted packng the shoppng nto bags andmem Pub 1 then removed t to the offce untl he was ready to leave at the end of the day. He then made hmself a cup of tea and returned to the kosk to releve Mem Pub 3 who went back to her usual poston on check out number four. Mem Pub 2 on Page 14

21 ncdent Reconstructon checkout number two normally started her lunch break at 1240 hours and ths occason was no dfferent. Havng selected a bar of chocolate for herself from the dsplay, Mem Pub 2 pad for t and was served by Mem Pub 3 after she was releved by Mem Pub 1 t can therefore be assumed that the tme would have been about 1241 or 1242 hours Mem Pub 2 then went to the staffroom after obtanng a cup of coffee from the vendng machne n the ktchen on her way. She had only been sat down for a couple of mnutes when the securty guard entered the staffroom and brefly conversed wth her about the newspaper she was readng before leavng about a mnute later sayng he was gong to see what Mem Pub 1 was dong wth the magaznes. The securty guard was leanng aganst the kosk when a male and female customer approached the duty manager n the kosk nformng hm of a fre 'down there' pontng towards the chocolate and nuts dsplay fxture adjacent to the entrance doors to the warehouse Mem Pub 1 left the kosk, went nto the store through the turnstles and towards the area where the customer had been pontng to nvestgate. At the sar:ne tme, the securty guard-was shoutng n a 'pancky voce' for a fre extngusher. He went nto the staffroom area and shouted to Mem Pub 2 to call the fre brgade as there was a fre and then he retreved a water extngusher from ts hangng bracket outsde the cash offce and returned nto the store to rejon Mem Pub 1 As he approached the fre, Mem Pub 1 could see red and yellow flames emergng from above the chocolate and nuts fxture whch were touchng the celng and he assumed that the fre was behnd the fxture, n the area used for the storage of boxed crsps and other savoury products. The securty guard clams that he dscharged the extngusher onto the fre althoughmem Pub 1 states that he judged the fre 'too far gone' and ordered the securty guard to leave the store. A male customer smultaneously told Mem Pub 3 on checkout number four of the fre and told her to get everyone out. She also heard Mem Pub 1 shoutng to get everyone out of the shop. She left her checkout and ran down the asle drectly n front of her tll towards the dary frdges and then alongsde the freezer area where she could now see smoke at celng level. She was qute worred by the volume of smoke and wanted to check that no customers remaned n the store before she left. She ran along another asle towards the rear of the shop where she also saw flames around the celng above the chocolate dsplay fxture. She notced the smoke gettng thcker and t dawned on her that the fre was n fact, qute serous. Mem Pub 3 then ran back towards the checkout area where she saw a man pushng a shoppng trolley who seemed oblvous to the fre and she ushered hm out of the store. She then entered the staffroom where Mem Pub 2 was speakng to the fre brgade on the telephone and was followed nto that area by the securty guard. She collected her coat and bag and returned va the door nto the store adjacent to the turnstles to be confronted by thck smoke whch had descended to wthn about one metre above the floor. She had been surprsed by how quckly the smoke had spread but just ran out through t to the man entrance doors and then outsde Mem Pub 2 meanwhle, was havng dffculty on the telephone explanng to the fre brgade, the exact address of the premses. Mem Pub 1 had by now returned to the offce where he was attemptng to operate the store tannoy system to make an announcement to any remanng customers to evacuate the premses. For unknown reasons, the tannoy system faled to operate. He then took over the telephone from Mem Pub 2 and gave the fre brgade detals of the Supermarket's locaton. Mem Pub 2 went to leave the premses va the same sngle door nto the shop area (whch was closed) and was confronted by thck black smoke creatng complete darkness wth no vson of anythng. She began to nhale smoke mmedately and crouched down towards floor level when she heard the securty guard mmedately behnd her tellng her to keep gong towards the man doors. She dd ths and eventually reached open ar where she saw Mem Pub 3 stood aganst a wall on the opposte sde of the road n the knowledge that Mem Pub 1 was known to be stll nsde the shop, the securty guard was unsure whether to go back nsde for hm but he was beng deterred from attemptng t because of the thck smoke bllowng out from nsde Whlst gvng the extra detals to the fre brgade, Mem Pub 1 was also becomng aware of the worsenng stuaton because smoke was by ths tme begnnng to enter the offce from whch he was speakng and he had to cut hs conversaton short. That call to the fre brgade was answered at 1246 and 14 seconds and ended at 1246 and 48 seconds When he attempted to leave the premses through the same door as the others nto the store, Mem Pub 1 found hmself trapped by the smoke wthn the shop area whch made everythng ptch black whch would have prevented hm from fndng hs way out. He therefore shut the door and went nto the ktchen and tred to open the wndows whch fronted onto Byron Place. The wndows had been made unopenable for securty reasons but the sght of Mem Pub 1 hands on the nsde of the wndow had been spotted by the securty guard outsde who then attempted to kck n an adjacent wndow. He was unsuccessful n the attempt because the glazng was Georgan wred andmem Pub 1 then pcked up a mcrowave oven whch he used as a ram aganst one of the wndows. After fve or sx strkes, the wndow was broken enough for hm to clmb out asssted by the securty guard and other (unknown) person. He was then able to rejon hs colleagues outsde opposte the man entrance to the Supermarket. 5.3 Ext Door An ext door was provded between the offce/staffroom area and the rear car park to open ar. t was not possble to establsh whethermem Pub 1 had attempted to escape through that ext before breakng out through the wndow. Ths factor s referred to later n the Report. Page 15

22 :::::s::::: en w Cl 3:: <:) ~ 3:: V) Cl::: ww C) U <C :z: <C ~ w ~ U -!J)LL «LL u ::::s:::::: :z w U f-- :::::s::::: ::=2: 0 0 0:::: W U LL LL LL «LL f- 0 en U :z: w m ~ f- w ---1 :z ~ Ul 5: 0 Cl :z 5: 0:::::: J LL 0 Z ~ 0 0::::: 0 (f) er:::: t f-- -LLJ wo::::o:::: z-o - O.-t-- 3: enuj Fgure 5: Showng ext door next to Manager's Offce Page 16

23 ncdent Reconstructon.,':-. : '~.:.-- "::...,... ".. '..., '",'," ",... ' /, '.;-'.., fre wth caller number three reportng smoke emttng from the man entrance and also seeng someone clmbng out of a wndow. Caller number sx tmed at 1251 hours was a neghbour who reported seeng flames dschargng through the roof. Ths report concded wth the arrval of the frst fre applance at the ncdent and the Offcer-nCharge, Sub Offcer confrmed the report n hs 1 statement The speed at whch events unfolded n ths ncdent are a vtally mportant factor n the tragc consequences that resulted. As prevously ndcated n Paragraph , the reconstructon of events on a mnute by mnute bass shows qute conclusvely that the crtcal tme span durng whch Fleur Lombard lost her lfe was a mere four mnutes - between 1308 hours and 1311 hours. Plate 8: Ext door /lext to Manager 's Offce (See Fgure 5) The followng secton (5.5) descrbes the Fre Brgade Actons n some detal, reconstructng all relevant freground actvtes smultaneously as they occurred throughout the ncdent. The account should be read n C) () (~ () Plate 9: Holed roof over Meat Preparaton Room 5.4 u Speed of Events Durng the seven mnutes followng the frst call at 1246 hours, a further ten '999' calls were receved at Brgade Control from passers-by and neghbours. The recordngs of those calls confrms the rapd development of conjuncton wth the ncdent Events Chart reproduced as Appendx 1 attached to whch s the detaled personal statement of Frefghter the team colleague of 9 Frefghter Fleur Lombard, who descrbes events at 1311 hours, consdered to be the crtcal tme (reproduced as Page 17 of Appendx 1). Whlst the ncdent Events Chart provdes for events occurrng from 1243 hours untl 1330 hours, only events relevant to the death of Fleur Lombard Page 17

24 ncdent Reconstructon were plotted on the chart and these occurred between 1244 hours (the approxmate tme the fre was frst dscovered) untl 1320 hours (the tme at whch the dentty of the deceased frefghter was confrmed). 5.5 Fre Brgade Actons The frst applance to arrve at Leo's was the Water Tender (WrT) from Staton B6 Speedwell, call sgn Bravo 61. The Offcer-n-Charge, Sub Offcer 1 saw a large plume of 'greysh' smoke rsng from the vcnty of Leo's whlst en route. The applance turned from Broad Street nto Byron Place (See Fgure 6) and proceeded past the man customer entrance doors towards the rear car park. Vehcular access to the car park was prevented by steel gates across the entrance but as Bravo 61 approached, the gates were beng opened by the securty guard whch allowed the applance to manoeuvre nto the rear car park (whch was empty), bookng n attendance at 1251 hours. t could clearly be seen that the fre had penetrated the roof and had breached a large hole n the corrugated asbestos roof coverng. The crew mmedately got two jets to work usng 45mm hose suppled ntally from the applance tank. These jets were drected from ground level towards the roof and nto the holed area. Sub Offcer 1 meanwhle, was consultng wth the securty guard and the duty manager, Mem Pub 1 n the rear car park about the buldng tself, the cause of fre and whether t was known f there was a lkelhood of anyone beng nsde the premses At 1252 hours, the second applance booked n attendance whch was the Water Tender Ladder (WrL) from Staton B7 Kngswood, call sgn Bravo 72. The Offcer-n-Charge was Sub Offcer2 who was rdng wth a crew of fve and automatcally assumed overall charge of the ncdent from Sub Offcer 1 as the ncdent was n the staton area of B7 Kngswood. Sub Offcer 1 beckoned Bravo 72 to stop alongsde the man customer entrance as they arrved va Byron Place. The drver of Bravo 61 was preparng to set nto a hydrant asssted by one of the crew who had temporarly closed down one of the jets. As Bravo 72 arrved, the crew of that applance also asssted wth the hydrant supply to Bravo 61 on the nstructons of Sub Offcer 2 who also ordered the breathng apparatus wearers to remove ther sets. Sub Offcer 1 meanwhle, had joned Sub Offcer 2 who consulted over Sub Offcer 2 proposal to 'make pumps four'. Ths was agreed and the message was sent at 1253 hours from Bravo 72, as a result of whch, one further pump was moblsed from B6 Speedwell and one from A1 Temple at 1254 hours. A Supervsory Offcer was also notfed and booked moble at 1255 hours and at 1256 hours, the duty Group Commander was nformed. Sub Offcers 1 and 2 went down Byron Place together towards Broad Street to carry out a reconnassance of the buldng. Sub Offcer 2 knew that the Labour Club was located above the store and when he arrved there he met an off-duty frefghter who he asked to ensure that the Club was evacuated. He then proceeded to an adjacent publc house to ntate evacuaton from there also and afterwards, returned to the rear car park where Bravo 61 was located. Sub Offcer 1 had already returned to the rear car park a lttle earler than Sub Offcer 2 and contnued talkng to the duty manager about keys to the buldng and the structure and compartmentaton Sub Offcer 1 nstructed the two frefghters from hs own crew who were operatng the two jets nto the roof to shut them down and get themselves rgged n breathng apparatus. Whlst they were dong ths, ther postons on the jets were taken over by one frefghter from Bravo 72 and one from Bravo 62 whch had just arrved. Bravo 62 was the Water Tender Ladder 0-Y/ rl) from Staton B6 Speedwell whch booked n attendance at 1257 hours wth Staton Offcer 1 n charge and a crew of fve Once rgged n breathng apparatus, the team from Bravo 61 were nstructed by Sub Offcer 1 to force an entry nto the buldng through' a fre ext door (adjacent to the staff locker room). They attempted, unsuccessfully, to sprng the door open and had to cut a hole n the door usng a large axe whch provded suffcent access to open the door by releasng the panc push bar nsde. They observed that the fre had reached the nsde of the ext door and the team (desgnated Team 1) were nstructed to make an entry wth a jet each to tackle the fre nsde. On enterng the short corrdor gvng access to the warehouse, (See Fgure 7) the team were aware of fre on both sdes of the corrdor whch they doused wth the jet and once at the entrance to the warehouse, they could see that fre had engulfed everythng n front and to the rght (n the meat preparaton room) and was stll burnng fercely n front and to the left (n the retal area) wth a red glow and consderable nose from the poppng of asbestos. The breathng apparatus Entry Control was set up outsde the entry pont n the charge of Frefghter 1 the drver of Bravo 61. t was not necessary to mpound the breathng apparatus Control Board from ths entry pont and therefore the tme of entry was not avalable for the nvestgaton. The breathng apparatus Entry Control was not ether desgnated a number at ths stage of the ncdent. For the purpose of the nvestgaton however, ths control pont was desgnated Entry Control Pont 1 as llustrated on the plan drawng. (See Fgure 7) The two frefghters who had temporarly taken over the jets whlst Team 1 were rggng n breathng apparatus, were themselves ordered to don breathng apparatus sets when the jets were retreved from them. They used the mddle two sets from Bravo 62 to form Team 2 comprsng Frefghters 10 (B62) and 6 (B72). When they had started up ther sets and gone through the entry control procedure, they were brefed to jon up wth Team 1 and operate one of the jets they were usng and allow Team 1 to pperate the other When Bravo 62 arrved n attendance wth Staton Offcer 1 n charge at 1257 the applance stopped n Broad Street ntally to allow Staton Offcer 1 to proceed on foot along Byron Place to assess the stuaton. As he dd so, he beckoned hs drver to proceed nto Byron Page 18

25 5!'.[OCQ,P[ FlUll ClL[l 1111lA! '.lcatss Byron Place ff<ml rloor Fgure 6: Broad Street and Byron Place Elevatons Page 19

26 \, \j CANNED Entry Control Pont 1 $) ~ '" N o ~ ~ ~ ;;0... ~. o ;os ~ M1 q

27 ncdent Reconstructon Place, whch he dd and stopped the applance at the rear of Bravo 72 adjacent to the man customer entrance. (See Fgure 6). Staton Offcer 1 then made hs way towards the rear car park to make contact wth another Offcer. As he dd so, he was followed by hs two breathng apparatus wearers, Frefghters 9 and Fleur Lombard who had already rgged n breathng apparatus whlst on route to the ncdent on the nstructons of the Staton Offcer but had not started up. Staton Offcer 1 met wth Sub Offcer 1 near the corner of the buldng at the juncton of Byron Place and the rear car park wth Frefghters Lombard and 9 standng alongsde. Sub Offcer 1 was n dscusson wth the duty manager, Mem Pub 1 at the tme and when Staton Offcer 1 joned them he heard Mem Pub 1 explanng that the rear of the buldng was a warehouse and the remander had been 'knocked through' to form a shop. He also told the Offcers that access to the man shop was also avalable through the man customer entrance n Byron Place. Staton Offcer 1 then dscussed the stuaton wth Sub Offcer 1 when the two of them were joned by Sub Offcer 2 At ths pont, (1259 hours) Staton Offcer 1 assumed command of the ncdent As a result of the conference between the three Offcers, t was decded that a new entry pont should be ntated through the man customer entrance on Byron Place usng four breathng apparatus wearers, two wth a hose reel and two to lay a gudelne. Frefghters Lombard and 9 remaned alongsde ther Offcer-n-Charge, Staton Offcer 1 throughout the conference wth the two Sub Offcers but were approached at one pont by a Polce Constable 1 of Avon and Somerset Constabulary, who was on duty at the ncdent. PC 1 had earler spoken to the duty manager, Mem Pub 1 who had nformed hm that the fre had frst been reported to Mem Pub 1 by a customer. He also sad that he had evacuated the store and had to smash hs offce wndows to get out. PC 1 askedmem Pub 1 f he was sure everyone was out of the store to whch he repled that he ddn't know. The PC, n company wth the duty manager then approached Frefghters Lombard and 9 and told them that 'there may stll be people nsde the shop'. Ths s a sgnfcant event n the proceedngs whch s referred to agan later n the Report. On hearng ths remark from the PC, Frefghter 9 ponted to the Staton Offcer and told the PC to advse hm (the Staton Offcer) about t. t would appear that the preoccupaton wth freground command prevented the PC from ganng the attenton of the Staton Offcer mmedately and t was not for some four mnutes later that the PC mentoned hs concerns to the Staton Offcer. (See Paragraph ) Havng agreed wth the two Sub Offcers that the next course of acton would be to send n the four breathng apparatus wearers 'n an attempt to stop the fre spreadng to the shop tself', Staton Offcer 1 nstructed Sub Offcer 2 to mplement that. Frefghters Lombard and 9 were stll present when ths nstructon was gven and Staton Offcer 1 nstructed the two breathng apparatus wearers to enter the buldng wth a gudelne and lay to the left. mmedately afterwards, Staton Offcer 1 Sub Offcer 2 and Frefghters Lombard and 9 made ther way towards the man customer entrance. Sub Offcer 1 had already returned to the frefghtng operatons at Entry Control Pont 1 and after nstructng Sub Offcer 2 Staton Offcer 1 went to jon hm at the rear to reconnotre the stuaton. At the man entrance, Frefghters Lombard and 9 were preparng to start up ther sets when Frefghter 5 one of the breathng apparatus wearers on Sub Offcer 2 crew, asked Sub Offcer 2 f he wanted them to rg n breathng apparatus also to whch he sad yes. Frefghter 5 and Frefghter 7 hs colleague from the crew of Bravo 72 then began rggng n breathng apparatus from the sets on ther own applance On seeng Frefghters Lombard and 9 preparng to start up ther sets, the drver of Bravo 62, Frefghter 8 retreved the breathng apparatus Control Board and resusctator from hs applance and began to set up the breathng apparatus Control. Several wtnesses at that tme, descrbed condtons nsde the store when vewed through the man entrance doors as 'heavly smoke-logged' wth thck grey/black smoke but wth no fre vsble. Frefghter 8 establshed a control pont outsde and to the left of the man entrance n a clear poston upwnd of any smoke. He heard the request from someone he could not later remember, for a gudelne to be used and as a consequence, he returned to hs applance to fetch one whch he took back to the control pont. The control pont, desgnated Entry Control Pont 2, was n stu at 1301 hours and a hgh pressure hosereel was run out from Bravo 72 by Sub Offcer 2 and Frefghter 4 anj left flaked out by the entrance. Staton Offcer 1 had at ths pont arrved at the rear of the premses where he was ntroduced to the General Manager of Leo's who had just arrved on the scene. Also at 1301 hours, the Supervsory Offcer, Assstant Dvsonal Offcer 1 booked n attendance at the ncdent and parked hs vehcle some ffty metres away n Broad Street where he proceeded to dress n hs fre kt Frefghter Lombard was weanng the only breathng apparatus set equpped wth 'Sonc' rado communcatons from amongst the four wearers and therefore assumed the role of team leader. The gudelne bag was consequently attached to her breathng apparatus harness usng the fastenng provded. Frefghter 9 attached the free end of the gudelne to a steel post affxed to the outsde of the buldng next to the breathng apparatus Control Board. Frefghter 8 then attached the gudelne dentfcaton tally 'B' to t by means of the dog clp attached. (Tally 'B' was used purely because t was the frst tally Frefghter 8 pulled out of the bag). Smultaneous to ths at 1302 hours, the fourth applance booked n attendance whch was the Water Tender (WrT) From Staton Al Temple, call sgn Alpha 13. The Offcern-Charge was Leadng Frefghter 1 rdng wth a Page 21

28 ncdent Reconstructon crew of fve who used hs freground personal rado to contact Sub Offcer 2 and repon hs attendance. The applance was parked on Byron Street behnd Bravo 62 and Leadng Frefghter 1 proceeded to the man entrance At 1303 hours Frefghters Lombard and 9 had completed ther stanng-up procedure and were gastght. They handed ther talles to Frefghter 8 who checked the names and cylnder contents n accordance wth standard procedure and entered the 'Tme-n' as 1302 hours. (NB: t was later dscovered that the breathng apparatus Board clock was set one mnute slow and the actual tme was therefore 1303 consstent wth the real tme of. reconstructon durng the nvestgaton). Frefghter 8 carred out a rado test to ensure that the 'Sonc' communcatons was operatng correctly, whch t was, and then nsened the talles nto the Control Board and desgnated the par as 'Team l' by bracketng them together on the board. He also wrote n the locaton of the team as 'L.H. Lay Hosereel' and gudelne dentfcaton as 'B'. No addtonal comments were made n the 'Remarks' column. Team 1 then left Entry Control Pont 2 and made ther way nto the buldng through the man customer entrance and then stopped n between the outer and nner sldng doors n a lobby area. After hearng much of the earler consultaton between the Staton Offcer and the two Sub Offcers n the rear car park and also hearng what Sub Offcer 2 had sad before ther entry, Frefghter 9 at ths pont was confused about ther precse tasks. He thought ntally that he and Frefghter Lombard had been expected to take n both the gudelne and the hosereel whch had been lad out n preparaton outsde. He recalls wonderng to hmself how they were gong to acheve those tasks when he realsed that a second breathng apparatus team were to jon them. Before that realsaton, Frefghter 9 expressed hmself n evdence as qute happy wth the prospect of takng both the hosereel and the gudelne because havng seen the fre development from the rear car park earler, he had formed the opnon that the man fre n that area was n hand and from hs entry pont, they were 'just dealng wth a normal smoke logged buldng'. He dd however, stll have n hs mnd that there may be persons stll nsde the buldng from the approach to hm by PC 1 whlst n the rear car park. Both Frefghter 9 and hs colleague Frefghter Lombard had heard the PC express hs concerns that there may stll be people n the buldng and nether of them had snce been told anythng dfferent At about ths tme (1304 hours) Staton Offcer returned from the rear car park towards the man entrance. On the way, he was approached by PC 1 who told hm that he beleved that 'there were stll people n the Labour Club buldng at the front of the Supermarket buldng'. When at the man entrance, Staton Offcer 1 was told by Sub Offcer 2 that the Labour Club had already been evacuated. As he stood by the man entrance doors whch were open, Staton Offcer 1 observed that the nsde of the premses were smokelogged wth stll, grey smoke and he also saw Team 1 (Frefghters Lombard and 9 watng n the lobby area and Team 2 (Frefghters 5 and 7 rgged n breathng apparatus and preparng to enter. Staton Offcer 1 then went towards the rear car park Havng dressed nto frefghtng unform, Assstant Dvsonal Offcer 1 approached the premses along Broad Street at approxmately 1304 hours and notced the doorway to starcase 'D' on the plan (see Fgure 8) gvng access to the Labour Club whch he consdered may gve access to the fre. The door was locked but there were glass panels n the doors whch were warm and showng evdence of smoke deposts on the nsde. After fndng them locked, he left the doors ntact makng the assumpton that the doors led nto the store area. (t was n fact a double ext door from the retal area of Leo's between the eggs and dary products fxtures). As he went back out nto Broad Street he 'notced members of the publc standng near the other doors to the Labour Club gvng access to starcase 'B' on the plan. Assstant Dvsonal Offcer 1 then proceeded towards what appeared to be the man frefghtng area lookng for the Offcer-n-Charge, Staton Offcer 1 As he made hs way along Byron Place, he noted that a breathng apparatus Entry Control Pont had been establshed together wth 'hosereels and an un-charged 45mm delvery hose and branch had been provded', As he passed the man entrance door he noted smoky condtons and could see a 'fant' red glow, apparently deep wthn the buldng. He assumed ths to be one sde of the fre. At ths pont, he notced Staton Offcer 1 at the corner of the buldng on the juncton of Byron Place and the rear car park whch was where they met. As they walked together through the rear car park towards Entry Control Pont 1, Staton Offcer 1 brefed the Assstant Dvsonal Offcer about the stuaton, The Assstant Dvsonal Offcer assessed the fre development through the door at Entry Control Pont 1 and could see fre 'to hs rght centre and left'. He assumed that the glow he had seen through the man entrance was the fre he could see to hs left. 5,5.14 Back at the man entrance at 1305 hours, whlst stll watng to enter the buldng, Leadng Frefghter 1 observed Frefghter 9 return to the Breathng Apparatus Entry Control Offcer (BAECO), confer wth hm, then return to the lobby. Frefghter 9 was able to confrm that he dd that to ratfy that ther bref was to lay the gudelne on a left-hand lay. At that tme, Leadng Frefghter 1 was met by Sub Offcer 2 who had come from the rear. Sub Offcer 2 told hm to get four frefghters rgged n breathng apparatus to get a jet to work nsde the buldng. Frefghters and 11 were so nomnated and Frefghter 11 once rgged, ran out a lne of 45mm hose. The BAECO then advsed Leadng Frefghter 1 that an emergency team was requred and after consultng wth Sub Offcer 2 Frefghters 14 and 11 were desgnated as the Emergency Team At 1306 hours, both teams made ther ntal entry. Frefghter Lombard was leadng and began to move towards the rght as they moved nto the nner lobby Page 22

29 BROAD STREET BEER~ SEPARATE OCCUPER FURNTURE OUTLET RETAL AREA Fgtm 8: Starcases 'B' and 'D' Page 23

30 ncdent Reconstructon towards the checkout area. On becomng aware of ths, Frefghter 9 shouted to her that they were supposed to be layng a left-hand lay. She mmedately returned to her colleague and Frefghter 9 made the frst 'te-off' of the gudelne on the tubular steel barrer whch enclosed the trolley park adjacent to checkout number one. Team 2 followed close behnd, carryng the hgh pressure hosereel whch was at ths stage charged, but not n use. Frefghter 9 recalled n hs evdence how he thought that they were expected to search as they proceeded and other teams would be followng them n. Team 1 were not at ths stage lnked together by personal lne, preferrng nstead to mantan physcal contact. As they made ther way through checkout number one they adopted the search technque and mantaned contact wth the wall to ther left hand sde. Ths took them down the beer/wne/sprts asle drectly n front of check out one and Frefghter 9 recalled feelng bottles on the fxture whch caused hm to realse they were n an asle. Because of the fxture desgn and the nature of the loose products dsplayed on them, Frefghter 9 had some dffculty fndng a sutable pont on whch to make the second 'te-off' of the gudelne. As the Team began to make ther way along the asle, Frefghter 9 remembers commentng to Frefghter Lombard that 'whenever the two of them are nomnated breathng apparatus wearers together, they always seem to get a 'job". He also told her that he could not seem to fnd any te-off ponts for the gudelne. Although Frefghter 9 remaned n physcal contact wth Frefghter Lombard as they proceeded down the asle, the smoke was so dense that he could only just make out the outlne of her breathng apparatus set mmedately n front of hm. The heat began to ncrease to the extent that they had to crouch down n an attempt to fnd a cooler atmosphere. They could hear a lot of bangng whch Frefghter 9 descrbed as smlar to aerosol cansters explodng but much louder. They made ther way along the asle untl they reached the end wall drectly ahead whch was n fact, the dsplay fxture contanng dary products. He attempted to make the second 'te-off' onto somethng about wast heght on the (dary products) fxture whch had a soft consstency. He sad to Frefghter Lombard whlst tryng to make the te-off that they could not stay n much longer due to the heat. Frefghter 9 states that the heat and nose at ths tme had 'ncreased dramatcally' wth 'loud bangng' and also 'consderable roarng' whch was 'gettng louder all the tme'. The ncdent Events Chart (Appendx 1) estmated the tme at ths pont as 1310 hours, some four mnutes after the ntal entry Also at 1306 hours whlst both teams were makng ther ntal entry, the condtons nsde were reported by Team 2 as "heavly smoke-logged wth thck black smoke down to about wast level. t wasn't constant, t was movng and cleared momentarly whch was suffcent to see the mmedate vcnty wth the trolleys and checkouts to the left and a clear area of floor drectly ahead". When Frefghter Lombard moved towards the rght n front of Team 2, the gudelne behnd her momentarly blocked ther way untl she went back over to the left. Whlst Frefghter 9 was makng the frst 'te-off' of the gudelne to the tubular steel barrer enclosng the shoppng trolleys at 1307 hours, Team 2 had contnued to make progress n a straght lne drectly ahead and parallel to the checkouts whch caused the two teams to become separated. Frefghter 7 stated at ntervew durng the nvestgaton that he had assumed n hs mnd's eye that there would be a wall to hs left, parallel to and behnd the checkouts whch he had surmsed would be the route of the gudelne. He therefore magned that the two teams would be movng forward together four abreast. t wll be noted from Fgure 9 that Team 1 n makng a lefthand lay, were n fact movng n a drecton at about 90 to the left of Team 2. As Team 2 advanced nto the store, Frefghter 7 led wth the hosereel and they knew there was a fre somewhere n front of them to the rght but vsblty was nl. The temperature was ncreasng to 'very hot' and n a short tme, they had reached an obstructon n front of them whch was the papers and magaznes fxture approxmately 17 metres from the pont at whch they had become separated from Team 1. They opened the hose reel at ths pont and played a spray jet onto the celng above them. Smultaneously, the temperature rose to an unbearable level very quckly and the water had been converted to steam whch began to burn ther exposed skn. They consulted each other and decded to retreat back outsde. Vsblty remaned at nl untl they reached the man entrance agan. The tme they decded to retreat was estmated at 1307 hours, whlst Team 1 was completng ther frst 'te-off' on the trolley park enclosure and startng to make ther way down the asle. When Team 2 reached the open ar, the tme was estmated as 1310 hours and durng the three mnutes that t took them to get out, Team 1 had progressed down the asle and arrved at the dary products fxture at the end At approxmately 1308 hours (the same tme that Frefghters Lombard and 9 were progressng along the asle), Sub Offcer 2 moved towards the rear car park and met wth Assstant Dvsonal Offcer 1 The Assstant Dvsonal Offcer asked hm to send an 'nformatve' message whch he ntated by dctatng the message to Frefghter 4 who transmtted t from Bravo 72 at 1309 hours as follows: fa buldng of one and two storeys, 80 metres by 40 metres, well alght, 8 breathng apparatus, 3 jets, 1 hgh pressure hosereel and 1 breathng apparatus gudelne n use' Team 2 retreated and returned to Entry Control Pont 2 and Frefghter 7 reported to Leadng Frefghter 1 that they (Team 2) were evacuatng. Frefghter 7 descrbed the deteroratng condtons nsde and when he establshed that Team 1 were stll nsde the premses, he urged that they also should be evacuated. Leadng Frefghter 1 then consulted wth Sub Offcer 2 and they agreed that the evacuaton sgnal should be sounded. Leadng Frefghter 1 nstructed the BAECO accordngly and also told Frefghters 12 and 13 not to start up ther breathng apparatus sets. (They were to become Team 3 and enter wth a 45mm jet). Page 24

31 l, c c c c G (-J u G G LJ u u u ~ U o o o.~ ~ ~ ~ ~ ~ "':! ~ N U1 "'1'1 0<; ' ~ nl ~ ;:,., Cl ~...!3l ~ 5:: ~ ~ ~.. ;:j :l.. c ~... c' ;:j ~ ~ ~ ~ SEPARATE OCCUPER FURNTURE OUTLET RETAL AREA Locaton of Fata ~ SPRT AND BEER,/\ f4l, U f3jcheck~t ( WX6 f2l CJ, [j,, L..-,, \ \ \ 1 1,, ', '1 ' OFFCE, ' :---t T-=- 1 1,,, STAFF RO()A 1,'-- L..----r -r--= B KTCHEN GROUND FLOOR Route of Team 2

32 ncdent Reconstructon Frefghter 8 (the BAECO) proceeded to blow hs whstle n the recognsed way at 1311 hours at the same tme pressng the transmt button on the personal rado to ensure t would be heard by Frefghter Lombard on the sonc communcatons equpment. After a few short blasts, he asked Frefghter 11 to contnue soundng the whstle n whch he was joned by Leadng Frefghter 1 whlst Frefghter 8 attempted to contact her by rado. He receved no reply but contnued to try. The evacuaton sgnal was heard by the breathng apparatus teams who were nsde the buldng from Entry Control Pont 1 and Frefghter 3 who was equpped wth 'Sonc' rado communcatons also heard the BAECO at Entry Control Pont 2 callng; "Frefghter Lombard, over" on a number of occasons but heard no reply. Both teams from Entry Control Pont 1 evacuated the buldng on hearng the sgnal and returned to ther BAECO. These events were tmed at 1311 hours Team 1 at 1310 hours meanwhle were engaged n makng the second 'te-off' of the gudelne at the bottom of the asle and experencng ncreasng heat, nose and roarng sounds. Wthn seconds of Frefghter 9 sayng to hs partner that they would not be able to stay n much longer, Frefghter Lombard shouted to hm "Evacuate, evacuate", whch Frefghter 9 presumed she had sad n response to a message she had receved over the rado. There was no recollecton by Frefghter 9 of hearng an evacuaton whstle at that tme and he was unaware what sgnal (f any) had been heard by hs Team Leader. The par mmedately turned towards the way out and took hold of each other's breathng apparatus harness to mantan physcal contact. Frefghter 9 recalled how the nose and blackness were frghtenng and as he looked up towards the celng, he could see flames lckng above them. He had hold of Frefghter Lombard's wast strap wth hs rght hand and the breathng apparatus gudelne n hs left hand. As they started to make ther way out along the asle, they were n a crouched poston but crawlng. The nose began to get ncreasngly louder whch they found scary and the explosons were makng them frghtened. They then began to ncrease ther pace to a trot and as they dd so, Frefghter Lombard began to move slghtly ahead of her partner but stll n physcal contact. Frefghter 9 then recalled the followng account of events at 1311 hours: "At that precse moment, somethng happened and my mnd went completely blank - the next thng, was on the floor thnkng must have fallen over. was thnkng 'where am?' and then began to recall what was dong before and when realsed, thought 'where's Fleur?'. The back of my neck and ears were hot and probably burnng and the condtons seemed to have been a lttle clearer f anythng but the heat was stll ntense. My hands felt hot where my tunc had rsen up my arms. As tred to regan my orentaton, could make out the outlne of a checkout. n the process of scramblng around to fnd the checkout, was wonderng what had happened to Fleur and recall hopng that she had got out. When felt the checkout, turned around and could make out the outlne of other frefghters n the entrance lobby. can't remember anyone helpng me out but when got nto the lobby, asked f Fleur had come out and when was told 'no', adrenaln just took over and grabbed a hose reel from someone else and scrambled over the trolleys towards the asle we had retreated from. remember around ths tme, someone askng where she was. remember seeng somethng on the other sde of the trolleys whch resembled a human and thnk knew t was Fleur. remember jumpng over the trolleys and saw her slumped forwards and n a crouchng poston aganst the wall. pulled her back and the breathng apparatus cylnder fell off whch brushed asde. Someone pcked her up under the arms and pcked up the legs and we carred her out to open ar and lad her down. After ths can't remember anythng untl was sttng n the ambulance". (The complete text of the above statement s appended as Page 17 of the ncdent Events Chart ncluded wth ths Report as Appendx 1). After placng hs colleague onto the floor, Frefghter 9 collapsed onto hs knees and was attended by ambulance paramedcs. He was asssted nto an ambulance, treated wth oxygen and conveyed to F renchay Hosptal, Brstol where he receved treatment for superfcal burns to the face, neck, ears and wrsts. He was detaned n hosptal overnght and dscharged the followng day Frefghter 7 of Team 2 was one of the frefghters n the lobby area operatng a hosereel when he spotted the legs of Frefghter 9 near checkout number one as the smoke momentarly cleared. He mmedately rushed forward and grabbed Frefghter 9 by the arm and guded hm towards the door to open ar. t was when Frefghter 9 establshed that hs colleague had not evacuated that he grabbed the hose reel from Frefghter 7 and went back nto the buldng followed by Frefghter 7 who was behnd when Frefghter Lombard was located and he asssted n recoverng her body to open ar n hs statement to the Polce, Frefghter 9 also stated that when he returned towards the asle to look for Fleur, he saw a fgure on the floor as he was tryng to move some trolleys whch appeared to be kneelng wth her head towards the wall. As he pulled her back by the shoulders, he sad that he could see t was Fleur but he could not see her breathng apparatus facemask or helmet. He also stated that her fre tunc and leggngs were burnt away at the front between her chest and knees At about 1310 hours the Assstant Dvsonal Page 26

33 ncdent Reconstructon Offcer returned to the man entrance, and heard shouts of 'Fleur's mssng', beng repeated. He mmedately ordered the l?reathng apparatus Emergency Team (Frefghters 14 and 11 to start up and ascertaned from the BAECO that the role of Team 1 had been to lay a gudelne on a left hand lay nto the man shop. He called for the man jet nto the doorway to be charged and ensured that the Emergency Team were aware that ther task was to follow the gudelne n search of the mssng frefghter. A second 45mm jet was lad out as the fre n the doorway was ntensfyng. He assessed that the ncdent would requre further frefghtng support and ntated an assstance message to 'Make pumps 6, hydraulc platform requred), whch was transmtted at 1311 hours. Frefghters standng n the vcnty of the man entrance doors at ths tme, reported becomng aware of an ntense wnd blowng nto the store from Byron Place whch was beng sucked n by the fre and of seeng powerful flames lckng from both sdes of the nner lobby beng bent nwards by the force of the wnd Sub Offcer 1 on hearng the evacuaton sgnals, moved from the rear car park to the man entrance to nvestgate and dscovered that a frefghter was mssng and crews were engaged n tryng to remove trolleys from the area of the entrance lobby. A general melee had at that tme broken out n the lobby area wth all avalable frefghters workng frantcally to remove trolleys from the parkng area. The trolleys were of the type that are normally chaned together and capable of separaton from the one n front only by the nserton of a con. Ths made the job of tryng to clear the trolleys more dffcult and attempts were made to release them usng bolt croppers On beng told by Leadng Frefghter 1 that Frefghter 9 had come out of the man entrance and that Frefghter Lombard was stll mssng, Assstant Dvsonal Offcer 1 asked Staton Offcer 1 to send a message to Brgade Control: 'Breathng Apparatus Emergency, one Frefghter mssng n fre'. The message was tmed at 1315 hours as the Assstant Dvsonal Offcer recalled n hs mnd, the doors on Broad Street whch he had examned when he frst arrved at the ncdent. Gven the layout of the buldng and hs knowledge of where Team 1 had been workng, he pondered the dea that one of those doors could possbly gve access to the mssng Frefghter. Almost n an act of desperaton, he mmedately made hs way to the Broad Street elevaton and approached frst, the ext doors provdng egress from the store nto starcase 'D'. (See Fgure 8). He dscovered a severe fre behnd those doors and concluded that Frefghter Lombard would not be there. He then went to starcase 'B' thnkng there may have been access nto the store and, havng found the doors secure, forced the one he thought was from the Supermarket to dscover that t was n fact, a door to a store cupboard. He therefore returned to the man entrance and on arrval, saw Frefghter 9 on the pavement recevng oxygen. The Assstant Dvsonal Offcer sought to establsh f everythng was n order and asked Frefghter 9 f he was alrght whch he ndcated by a 'thumbs up' and a nod of the head that he was. The Assstant Dvsonal Offcer was then approached by an ambulance paramedc who asked hm f he wshed to have a look at the body. Ths was the frst tme he realsed that Frefghter Lombard must have pershed and ths was confrmed when he lfted the salvage sheet and vewed the deceased The ambulance paramedcs took over the care and removal of the deceased to Frenchay Hosptal havng been satsfed there was nothng they could do to hep, lfe havng obvously become extnct. Frefghtng operatons had appeared to the Assstant Dvsonal Offcer to have come to a halt and he called for dutes to recommence, at the same tme nstructng crews not to enter the buldng. By that tme, he could also see a severe fre through the man entrance whch Leadng Frefghter 1 attempted to supervse wth the Frefghters remanng near the entrance. Further applances contnued to arrve as a consequence of both the 'make-up' message to sx pumps and the Breathng Apparatus Emergency whch also trggered the moblsaton to the ncdent of two further pumps, a rescue tender, a breathng apparatus servce vehcle, an ambulance and an addtonal Supervsory Offcer At 1327 hours, the (then) Deputy Chef Offcer1 booked n attendance when, concdentally, Assstant Dvsonal Offcer 1 had ntated a rado message to Brgade control at 1328 hours: 'From Assstant Dvsonal Offcer 1 one female Frefghter severely, request attendance of duty Prncpal Offcer'. The Assstant Dvsonal Offcer and the Deputy Chef Offcer made contact shortly afterwards and the Deputy Chef Offcer was brefed about events followng whch he nstructed Assstant Dvsonal Offcer 1 to wthdraw all personnel assocated wth the frst four pumps n attendance and arrange for them to be releved of operatonal dutes and wthdrawn from the freground to Staton B6 Speedwell. Followng ths nstructon, Temporary Dvsonal Offcer 1 (C02) assumed charge as Freground Commander untl releved by CO 1 at 1353 hours wth the Deputy Chef Offcer n overall command as ncdent Commander. The Deputy Chef Offcer ntated a further message to Brgade Control at 1343 hours: "From Deputy Chef Offcer, make pumps ten". The 'fre surrounded' message was ntated by the Deputy Chef Offcer at 1440 hours: Page 27

34 ncdent Reconstructon ((From Deputy Chef Ojfcer, fre surrounded, 10 jets, TTL montor n use, all persons wthdrawn from buldng. Frefghtng operatons wll contnue for some tme". The (then) Chef Fre Offcer booked n attendance at 1522 hours and frefghtng contnued wth the 'stop' message beng transmtted at 1643 hours. ((From Deputy ChefOjfcer, stop for Leo's, Broad Street, Staple Hll, 10 jets, 1 aeral montor, 8 Breathng Apparatus, 2 casualtes removed, 1 severely, relef crews detaned some tme". The ncdent was fnally closed at 1804 hours on Thursday, 8 February after extensve nvestgatve procedures, turnng over and dampng down operatons. As a result of the severe damage and the dangerous condton of the remanng structure, the premses were completely demolshed shortly after the fre. Page 28

35 6 Cause of Fre 6.1 Reportng Procedures All fres attended by fre brgades are nvestgated to establsh the 'supposed cause' whch s ultmately recorded on Form FDR1 (94), the statutory 'Report of Fre' compled by brgades and used by the Home Offce to produce the natonal fre statstcs. Such nvestgatons are conducted by or on behalf of the Offcer-n-Charge of the ncdent both durng and after frefghtng operatons as an ntegral part of the overall nformaton and data requred to complete the Report of Fre. Certan categores of ncdent requre addtonal, more detaled reportng, one of those beng ncdents where a fatalty has occurred. By fallng nto that category, the Leo's fre gave rse to the need for such addtonal reportng as detaled n Paragraph of ths Report. The fact that the fatalty n ths case was also an operatonal frefghter precptated an addtonal need to broaden the normal nvestgaton parameters for nternal audt purposes over and above the statutory nvestgaton requrements. To mnmse duplcaton of effort, the customary Fre nvestgaton Report was confned to a 'Cause of Fre' report whch addressed only those matters concernng the nvestgaton nto the actual cause of fre, the remanng ssues beng addressed n the body of ths Report. The 'Cause of Fre' report was prepared as the result of a jont nvestgaton by Polce CD, scenes of crme offcers, forensc scentsts and the fre brgade. The fre brgade offcer leadng that part of the nvestgaton was Dvsonal Offcer 1 whose separate 'Cause of Fre' Report s summarsed n ths secton. The statement of Sc 1 CChem, MRSC, the Senor Forensc Scentst nvolved n the nvestgaton has also been a source of reference n preparng the summary of the cause of fre. seen emttng at celng level mmedately afterwards was produced by the cardboard boxes. Ths supports the theory that the fre started n the boxes of pads stored n the north west corner of the meat preparaton room. 6.3 Conclusons about Cause of Fre Havng dscounted all other possble causes by a process of systematc elmnaton, the consensus of opnon was that the fre started n or n the vcnty of the north-west corner of the meat preparaton area. t had not been ntated usng any volatle lqud accelerant or as the result of a smoulderng source and had therefore been started delberately whch 'may have been ntated by a naked flame between about twenty and thrty mnutes before beng seen n the sales area of the shop'. The securty guard on duty n the store at the tme of the fre was charged n connecton wth the fre and at the tme of preparng ths Report, further detals are sub judce. 6.2 Seat of Fre Usng ndependent wtness descrptons about the dscovery of fre and ts early development, all of the professonal agences nvolved n the nvestgaton were n agreement that the fre started n the meat preparaton room. A more detaled examnaton revealed the pont of orgn to have been n the north-west corner of the room. Wth the assstance of the butcher who worked n the meat preparaton room and the co-operaton of CRS, t was possble for the nvestgaton team to reconstruct the area to ts layout before the fre as a result of whch, electrcal causes were elmnated. (See Fgure 4) Samples of the absorbent pads were subsequently tested n a Cone Calormeter at the Fre Research Staton, Garston, Watford, the Test Reports of whch form Appendx 2 of ths Report. The conclusons ndcated that the pale smoke wtnessed when the fre was frst dscovered was produced by the absorbent pads and the black smoke Page 29

36 LCCCGCCCGOGOOOOO~~~~~~~ of ~ :l;- d' 5' '" ~ o '< c}q ' ;:;. ~ ::n ~ HAND WASH ELECTRC WTH HEATER OVER SNK WTH ELECTRC DSPOSAL UNT UNDER ELECTRC OVERWRAP MACHNE F /~ ELECTRC GRNDER / -W..8.S.l E DSPOSAL TANK VEW EGG Y OSPLA 0. - REA L ROLLS OF / HEATWRAP / POLYSTYRENE -T -l=- -l\f _ T-t: ~ ~ BEAUTY COFF[ MEAT BOXES OF ABSORBENT PADS ~O~ HERY~} ~ MEAT PREP.ROOM Pont of Orgn '"0 'l CtQ (1) \,;j o

37 7 Cause of Death 7.1 Custody of Deceased The deceased was conveyed from the freground by ambulance to the Accdent and Emergency Department at Frenchay Hosptal, Brstol where Doctor 1 the Casualty Offcer, pronounced Frefghter Lombard dead. The body was then conveyed to the Hosptal Mortuary by the same ambulance paramedcs who formally dentfed the body to Polce Constable 2 before transferrng custody to the Mortuary Techncan, Mortuary Postmortem Examnaton The postmortem examnaton was carred out at Frenchay Hosptal on 5 February 1996 by the Consultant Hstopathologst, Doctor 2, MB, B.Ch, FRCPath The external examnaton was reported as showng extensve full thckness burns nvolvng the entre head and neck, chest, upper part of the abdomen, trunk, both upper arms, both forearms and both hands. The skn had ruptured n many places to expose underlyng skeletal muscles and n some places underlyng bones. There were extensve burns to both thghs and both legs but most of these burns were only partal thckness. Superfcal partal thckness burns were present on both feet. Where ntact skn could be seen, ths showed some pnk dscolouraton n places The examnaton of the respratory system revealed that the larynx, trachea and other major ar passages contaned a moderate amount of soot and the mucosa of the upper respratory tract was markedly congested n places. Both lungs were oedematous, congested and focally haemorrhagc n places. There were extensve burns to the mouth and the tp of the tongue was burnt. upon the respratory system as outlned n above, ndcates that death would have been vrtually nstantaneous once the face mask had become detached. 7.3 Recorded Cause of Death n the opnon of the pathologst, the cause of death was offcally recorded as: la Shock 1 b Extensve burns 7.4 Evdental Factors When the nvestgaton Team attempted to recover the remans of the frefghtng unform beng worn by Frefghter Lombard at the tme of her death, t was dscovered that all remans had been ncnerated by the hosptal. Ths severely hampered one lne of nqury to assess the precse condtons endured by the deceased and to dscover how the frefghtng unform behaved n such condtons. Whlst ths was a farly sgnfcant set back whch could have provded valuable evdence concernng the protectve clothng and equpment, the evdence produced from test results of clothng fragments and expert opnon has provded a realstc alternatve source of evdence The extent of burnng to the body and the reacton of surface tssue showed evdence of beng exposed to extremely hgh temperatures gven the fact that the tmespan nvolved has been estmated at around three mnutes between the supposed flashover and the dscovery of the body. Further comment s made about ths aspect later n the Report Analyss of a blood sample revealed the level of carboxyhaemoglobn to be 4% The postmortem examnaton revealed no other remarkable features from the detaled examnaton of other organs and functons and no further laboratory examnatons were deemed necessary by the pathologst Conclusons that may be drawn from the foregong postmortem examnaton s that there was nhalaton of smoke, hot gases and flame before death actually occurred. Ths would suggest that the breathng apparatus facemask became detached from the wearers head at some pont although the degrees of damage nflcted Page 31

38 8 Fre Development J ) J () 8.1 Background The wdespread natonal press coverage whch ths ncdent anracted caused the Fre Research Staton (FRS) at the Department of the Envronment's Buldng Research Establshment (BRE) to contact the Brgade as a result of whch they were nvted to vst the ste and provde assstance wth the nvestgaton. Although fortutous n orgn, the assstance provded by the FRS has been nvaluable to the nvestgaton Team n producng scentfcally based theores about the behavour and development of fre at ths ncdent. The opportunty s taken to record specal thanks to the FRS for ther unstntng help and co-operaton and n partcular to BRE 1 for the avalablty to the Team of her consderable knowledge and expertse n the feld of fre research. Trbute s also pad to the Department of the Envronment for classfyng the Leo's ncdent as a specal case and therefore permnng the Brgade access to the vast resources of the FRS The FRS team, comprsng BRE 1 BRE 2 (Human Behavour) and BRE 3 (photographer) vsted the freground on Frday, 9 February 1996 for a full ste survey durng whch they took photographc and vdeotape recordngs throughout the buldng remans. They were brefed on the conclusons of the nvestgaton nto the cause of fre together wth the seat of orgn and the Plate 10: Vew of cold stores (redundant one n foreground) materals beleved to have been frst gnted. By courtesy of CRS, the FRS team were also suppled wth dentcal fullsze packaged samples of both the polystyrene trays and the absorbent pads used n the packagng of meat products and beleved to have been the materals whch contrbuted to the development of the fre. 8.2 Route of Fre Spread The FRS team concurred wth the conclusons of the nvestgaton nto the cause of fre and ndeed, the pont of orgn n the north-west corner of the meat preparaton room. To reconcle the evdence concernng smoke colouraton n the early stages of the fre and to provde an ndcaton of development tmes, the sample pads and polystyrene trays suppled by CRS were taken back to the FRS laboratory to enable some ad-hoc tests to be conducted. The detaled results of these tests form Appendx 2 of ths Report t was the consdered opnon of FRS that havng establshed burnng n the meat preparaton room, the smoke and hot gases produced would have rsen to the celng and warmed the panted fnsh on the undersde of the fbreboard celng panels whch would have radated heat down onto the combustble packagng materals and egg boxes stored at low level n that room. As the materals frst gnted began to ntensfy, the other materals would lj u (~ \~ Page 32

39 Fre Development become nvolved thereby warmng the redundant cold store beng used for the storage of packagng materals. As the constructon of the store was of steel faced sandwch panels enclosng a tmber framed structure nsulated wth polystyrene nfl, there was every lkelhood of fre penetraton nvolvng the polystyrene thermoplastc core. n due course, the melamne faced partton walls would have started to burn and the fre would have moved out of the meat preparaton room at hgh level. Due to the absence of any fre separaton wth the retal area the percolaton of smoke and eventually flame, was able to travel unhndered nto the retal area. At the same tme, lateral heat transfer would have nvolved the crsps and savoury snacks stored n the ds-used delcatessen As stated prevously, the crsp store was separated from the retal area only by the chocolate and nuts dsplay fxture above whch was an open gap between the retal and storage areas. The crsp store tself was accessed from the meat preparaton room through an open doorway from FRS would therefore expect a reducton n peak heat release to somethng n the range of 1 to 2 MW and a total heat release of about 1500 MJ over 40 mnutes Exstng FRS data on the behavour of melamne faced chpboard (beng the constructon of the partton walls) shows that the contrbuton from the nvolvement of ths materal would ndcate a peak heat release of 3.6 MW and a total heat release of 183 MJ from 34 sq metres of materal. The contrbuton of the polystyrene materals would have produced a hgh heat output of short duraton whle the other materals n the area of fre orgn would have contnued burnng for consderably longer, and 40 mnutes would, n the opnon of the FRS, be a conservatve estmate Takng account of the above factors, the FRS estmated that the peak heat release from the meat preparaton room to be n the order of 8-10 MW wth a total heat output of over 2000 MJ. Such heat can be compared to 'J J J J ),,-) Plates 11 & J 2: Vew o/crsp Store wth redfloor coverng. Note rear o/freestandng dsplay fxtllre/ormng parttol/ wth retal area alld opell doorway ll stud partton from meat preparaton room (photograph on rght) whch the door had been removed. Once the heat from the orgnal fre had radated down onto other combustble materals on dsplay n the retal area, ther temperatures would have been rased and gnton would follow very rapdly allowng the fre to spread extremely quckly. 8.3 Heat Output that generated by 800 to 1000 sngle bar electrc fres swtched on at the same tme or 4 to 5 polyurethane foam flled two-seater settees burnng. (One two-seater polyurethane foam flled settee produces about 2 MW of heat). n the opnon of the FRS, such heat release would certanly have provded suffcent energy to gnte and sustan the burnng n the sales area. ~ t was possble to establsh that approxmately 100kg of potato crsps and savoury products were stored n the crsp store at the tme of the fre. From exstng data on potato crsps n bags, the FRS know that approxmately 70kg of crsps n bags on metal shelvng provdes a peak heat release of lmw and a total heat release n the order of 1000 MJ over 20 mnutes. As the products at ths ncdent were stored n cardboard boxes, t s estmated that the crsps etc would have become nvolved sequentally and the 8.4 Crucal Factors t has been suggested by FRS that the crucal factors havng a major contrbuton to the severty of the fre would probably have been: (a) the presence of hghly combustble materals n the area of orgn; Page 33

40 Fre Development (b) the absence of fre separaton between the meat preparaton room and the retal area and between the storage areas and the retal area; havng an ndex of performance of 1 but not exceedng 12 (on a range of where 1 s best), of whch not more than 6 shall derve from the ntal (three mnute) perod of the test. (c) (d) (e) (0 the exstence of a fbreboard celng wth a contnuous vod above t; the unsystematc fre safety management procedures demonstrated by the Leo's staff present at the tme; the absence of sprnklers and automatc fre detecton for early control and dscovery of the fre; the hgh fre loadng wthn the supermarket as a whole. 8.5 Fbreboard Celng Fbre buldng boards are manufactured n a wde range of sheet materals of varyng thcknesses usually composed of wood fbres or woody plants, they derve ther basc strength and coheson from the bondng together of the fbres themselves and from the nherent propertes of the adhesve used n the bondng process. The process also enables the materals to be mpregnated wth other agents ncludng fre retardants. Fbre buldng boards are produced usng several varatons of ths basc process to make, buldng boards, celng panels, nsulatng boards, hardboard etc. The type used to form the false celng at Leo's was of the low densty non-compressed type utlsed for ts nsulatng propertes t follows that because all fbre buldng boards are wood, they nhert the combustblty of the parent materal although they also carry ts nherent fre endurance. As stated n the prevous paragraph, enhanced fre retardant propertes can be acheved by the ntroducton of agents durng the manufacturng process but to be attrbuted levels of fre resstance, the fnshed materals have to satsfy the standards of Brtsh Standard BS 476. When the Fre Certfcate was ssued to Leo's n 1973, the relevant standard to whch the celng should have compled was BS 476: Part 7,1971- Surface Spread of Flame Test (amended n 1987). There are four classfcatons under ths test whch ndcate performance levels rangng from Class 1 to Class 4 (Class 1 ndcatng very low surface spread flame) whch relate to the behavour under specfed test condtons of nternal wall and celng lnng materals. An amendment to Part E 14 of Buldng Regulatons n 1971 ntroduced the use of BS 476: Part 6, Fre Propagaton Test as a legal requrement whch had to be satsfed n the case of materals used for wall and celng lnngs on escape routes. A new Class 0 was therefore ntroduced wth that classfcaton defned as ether: a non-combustble materal throughout, or The fbreboard celng nstalled n Leo's Supermarket was specfed by the Fre Authorty before ssung the Fre Certfcate as beng requred to conform to Class 1 performance n accordance wth BS 476: Part 7, There s no reason to beleve that that requrement was not satsfed at the tme of constructon whch s beleved to be When heated, fbreboard produces volatles from a decomposton of the adhesve components whch can be flammable. The FRS nvestgated a sudden fre development n a large chalet bungalow n 1992 n whch the volatles from a fbreboard celng became suddenly nvolved some mnutes after the fre started. The tmespan n the Leo's ncdent between dscovery of the fre at about 1244 hours and the supposed flashover at about 1311 hours would appear to concde wth those fndngs. The FRS beleve that the supposed flashover could well be attrbuted to the volatles from the fbreboard celng becomng fully nvolved n the fre and movng under the celng towards the wall where Frefghters Lombard and 9 were. t s relevant to note also that the FRS beleve that ageng fbreboard has a reduced lkelhood of satsfyng BS 476 and they have experence that the classfcaton could be degraded to Class 2 or 3 - 'low' or 'medum' graded surface spread of flame compared to the 'very low' gradng of Class 1 through degradaton over tme. 8.6 Supposed 'Flashover' The evdence avalable from the nvestgaton together wth scentfc and expermental factors led the FRS to the supposton that a flash over occurred, probably at the tme that Frefghter 9 experenced the 'dsorentatng occurrence' at about 1311 hours. Ths would be consstent wth research undertaken n Sweden whch has shown that smoke and hot gases at hgh level over a large area radate heat downwards and n the process of warmng the combustbles at low level, produce volatles whch rse to the hgher level. When temperatures reach around 550 C+ or -50 C, a flashover wll occur. All evdence n the Leo's fre supports ths theory whch was charactersed by the followng factors: a large compartment wth a relatvely low celng a hgh energy fre producng hgh levels of thermal radaton from ts plume volatles beng produced at hgh level from the fbreboard celng panels excesses of combustble fuels all around surface obstructons across the celng wtness accounts just pror to the flashover, of a large nrush of ar through the man entrance 'of wnd force' proportons. Page 34

41 Fre Development t s consdered somewhat unusual for a flashover to have occurred n a compartment whch has ventlated tself through the roof. Ths phenomonem cannot be explaned wth any certanty although there appear to be three prncpal factors whch may have contrbuted to the condtons: (a) the premse was n essence a large open plan compartment n whch was burnng a hgh energy fre. Ventlaton was provded by open doorways at both the man customer entrance and by the ext door to the rear car park (ECP 1). Bult-n ar brcks also provded a throughput of ventlaton and t s concevable that ncomng and outgong ar was out of balance affectng the movement and turbulence of the hot flammable gases at hgh level; (b) the two frefghtng jets n use from the southern sde of the store -e those workng through ECP 1, may have drven hot gases nto the buldng thereby affectng the turbulence of the hot gases at hgh and low level; temperature whch were local to her poston beng close to the wall. Ths would explan the severty and speed of the burnng njures to the head, shoulders and front of the fatalty The localsed nature of the deepenng of the gases would also explan why Frefghter 9 escaped the worst effects of the flashover by beng slghtly further away from the wall than Fleur Lombard. He would have felt the effects of the flashover as a 'blast' of pressure thrustng upon hm whch momentarly caused hm to lose hs balance and orentaton n the ml-seconds durng whch the 'event' took place. Any vsble warnng of the phenomenon by the presence of ncreasng flame actvty would have been obscured by the dense smoke although the personal account of Frefghter 9 at the relevant tme makes reference to ncreasng heat and nose whch would both be conssten~ wth the symptoms of an mmnent flash over whch they had already taken steps to avod by evacuatng. (c) the effects of the dfferental n the heght of the celng above the wnes and sprts asle coupled wth other obstructons created by upstands, downstands or advertsng boards could have affected the turbulence of the hot gases and when the gas layer was lowered, the thermal radaton would ncrease thereby ncreasng the producton of volatles at low level resultng n the gap between upper layers and lower layer becomng ever smaller. 8.7 Fatal Effects The volatles provdng fuel for the flashover would have been gnted by the growng fre around the central area of the store. The flames from ths event would have flashed across the store at hgh level untl an obstructon was met. As the flame travelled from east to west, t would have been deflected by the obstructon of the wall formed by the beers, wnes, sprts dsplay at whch pont t would travel n a downward drecton towards floor level untl met by another obstructon such as a dsplay gondola or a frefghter. Whlst such a behavour pattern was supportedby the burnng of labels on the beer can dsplays nearby caused by flames sweepng past, t could also be the result of low level turbulence at an even later stage n the fre. The preferred theory of the FRS s that the very hot layer generated under the celng from the burnng fbreboard volatles moved rapdly, at about 4-5 metres per second, towards the breathng apparatus team n the asle and exhbted the phenomenon known as 'local deepenng' as the layer met the wall. That deepenng layer s beleved to have curled down to floor level as the flame temperature gases met the obstructon, the hot gases havng been sustaned rather than transent. The FRS research to support that hypothess used thermal flows rather than flame temperature gases but that s consdered qualtatvely smlar for buoyancy drven gas flows as would be expected n ths type of fre. On the bass of ths theory, the most probable scenaro s that Frefghter Fleur Lombard was n the path of the sudden deepenng of gases at flame Page 35

42 9 General Breathng Apparatus Procedures 9.1 Polcy Gudance n order to satsfy the requrements of the Control of Substances Hazardous to Health Regulatons 1988 (COSHH) whch were made under the Health and Safety at Work Act 1974, the fre servce s guded by natonal arrangements and procedures for the use of breathng apparatus (BA). The arrangements are establshed by the Jont commttee on Fre Brgade Operatons under the auspces of the Central Fre Brgade Advsory Councl (CFBAC) and publshed by the Home Offce as Techncal Bulletn 1/89 whch was last ssued n September The Techncal Bulletn provdes gudance on operatonal procedures, equpment, BA tranng, routne dutes assocated wth BA and mscellaneous matters such as compressors and smoke generatng equpment. The bulletn states n ts preface: "t reflects the carefully consdered vews of the Jont Commttee and s offered to the Fre Servce n the earnest hope that the gudance t contans wll be followed ntellgently and n the lght of the partcular crcumstances n whch breathng apparatus s worn n the course of duty. t does not and cannot clam to be the last word on a subject whch s lable to technologcal change, adaptaton and refnement". Avon Fre Brgade adopted the Bulletn n ts entrety as Brgade polcy devatng from ts gudance only where a hgher standard was set locally or where local practces requred clarfcaton. Any such devatons are clearly dstngushed n addton to the gudance contaned n the Bulletn whch s ncorporated nto the Brgade polcy document enttled "Operatonal Procedure and Techncal Tranng nstructon" - A24 (O&T Note). Ths forms the bass of all operatonal BA procedures and tranng condtons throughout the Brgade and was the pont of reference for the nvestgaton. 9.2 Controllng Procedures The s8-fe wearng of breathng apparatus n fre brgades s secured, by extremely strct and precse controllng procedures whch are contaned n Techncal Bulletn 1/89 and apply natonally on all occasons when BA s used both n operatonal and tranng condtons. t s a requrement that BA s only used on the nstructons of the Offcer-n-Charge of the ncdent whose responsbltes n ths regard have to be balanced between operatonal objectves and the need, as the agent of the employer, to protect those employees wthn hs jursdcton from unwarranted exposure to hazardous condtons n accordance wth the requrements mposed on fre brgades by the COSHH Regulatons to "take all due dlgence to prevent the exposure of frefghters of rsks to ther health» t s a fundamental prncple of the controllng procedures that all fre brgade personnel nvolved n the use of BA are both properly traned and thoroughly conversant wth all aspects of the controllng procedures. Because those procedures rely entrely on team effort, t s of paramount mportance that everyone concerned, whether a BA wearer, a BA controller or a part of the support arrangements, should have suffcent confdence n the arrangements and the competence of ther colleagues as to feel as safe and secure as possble whlst carryng out ther job. To ths end, great emphass s placed on tranng n BA whch s referred to agan n a later secton of the Report The central feature of the controllng procedures s a BA Control Board whch s supervsed and operated by a BA Entry Control Offcer (BAECO). The BA Entry Control Board s desgned to hold talles whch are normally an ntegral part of the BA set when not n use but are detached from the set and handed to the BAECO at the commencement of use. The talles contan exclusve nformaton desgnatng the brgade, staton, set number, type of set, capacty of cylnder, name of wearer, cylnder pressure at tme of entry and the actual tme of entry. When nserted nto ndvdual transparent slots n the BA Control Board, addtonal nformaton s over-wrtten by the BAECO n wax pencl detalng the 'tme of whstle' - (the tme that ar n the cylnder s becomng exhausted), the locaton of the BA wearer/team, the gudelne dentfcaton (see paragraph 9.4) and addtonal remarks. The BA Control Board also has provson for other nformaton to be recorded by the BAECO ncludng hs/ her name, the locaton of the Entry Control Pont, the number of the control pont, the stage of entry control procedure (see below) and the avalablty of resusctaton and emergency wearers. t s also part of Avon Fre Brgade's polcy that the set number recorded on each tally s over-wrtten onto the BA Control Board should a tallv become nadvertently detached for any reason. t s also 'a Brgade polcy that BA wearers enterng as a team are bracketed together to so ndcate and that the wearer wth the lowest cylnder pressure on entry s dentfed by means of an astersk The controllng procedures prescrbed n Techncal Bulletn 1/89 are graduated n accordance wth the sze and scale of an ncdent. t s an mplct part of the procedure that BA Control wll be mplemented on all occasons that BA s used. The mnmum level of BA Control s known as 'Stage l' whch s nsttuted as soon as the decson to use BA has been taken by the Offcer-n Charge. Strct lmtatons are prescrbed restrctng the use of Stage Entry Control procedure to the followng Crcumstances: Page 36

43 General Breathng Apparatus Procedures (a) (b) (c) where the sze of the ncdent s small and the use of BA s unlkely to be protracted; where no more than two entry control ponts are used; where the total number of BA wearers n the rsk area does not exceed ten. Stage BA Control Procedures were n use at the Leo's ncdent at the tme of the fatalty whch was entrely consstent wth the above crcumstances. Provson exsts to upgrade BA control to Stage (see below) should crcumstances change as an ncdent progresses. At the tme that BA was mplemented at Leo's at both Entry Control Pont 1 and Entry Control Pont 2, there was no reason to beleve n frefghtng command terms, that the ncdent would eventually become ether 'large' or 'protracted' as prescrbed n paragraph (a) above. t would n any event, be normal practce f BA was beng put nto use, to commence wth Stage Control procedures untl such tme as suffcent addtonal resources were n attendance at the ncdent to upgrade to Stage rather than delay the use of BA untl that tme. The other condtons prescrbed n paragraphs (b) and (c) above were compled wth havng 2 Entry Control Ponts n use and a total of 8 BA wearers, plus ultmately, 2 addtonal BA wearers standng by as an Emergency Team Techncal Bulletn 1/89 stpulates n respect of the dutes of the Stage Entry Control Offcer that: "When personnel resources permt, two BA wearers should be kept avalable at the Entry Control Pont for emergency purposes". Avon Fre Brgade's O&T Note A24 stpulates n ths regard that: "f sx or more BA wearers are commtted nto the rsk area, an Emergency Team MUST be provded". The ncdent Events Chart (Appendx 1) shows at 1304 hours, that the BAECO at Entry Control Pont 2 requested two addtonal BA wearers as an Emergency Team whch were mmedately provded, before Teams 1 and 2 had entered the premses. Such actons were entrely consstent wth the polcy requrements The BAECO s normally the ffth member of a fre applance crew of fve who s specfcally nomnated as the BAECO at the commencement of the shft. Where a crew conssts of only four members, the drver normally assumes the role of BAECO f requred durng the shft, n addton to hs other dutes. BAECO's have a number of specfc dutes and responsbltes n that role and would always be qualfed BA wearers themselves. The dutes of Entry Control Offcers (Stage 1) are appended to ths Report as Appendx 3. Among them s the duty to receve the BA tally from a wearer and n so dong, check that the name of the wearer and the cylnder content at the tme of entry are correctly recorded on the tally. The actual tme of entry s then recorded by the BAECO onto the tally as "Tme n" and the tally s nserted nto the approprate transparent slot on the BA Control Board. Usng a 'Dorset type' calculator scale affxed to the Board, the BAECO can read the duraton of the set whch s recorded onto the Board as 'Tme of Whstle'. (!he 'Tme of Whstle' s the tme at whch a low press/n'e warnng whstle sounds to warn the wearer that the full workng duraton of the set has expred and only a safety margn of ar supply remans n the cylnder. By contnuously checkng cylnder contents on the set pressure gauge, a weal'er should ensure that hslher team wthdraws from the rsk area wthn the workng duraton so as to have returned to the Entry Control Pont before the low pr'essl/re warnng whstle has sounded. The warnng whstle sounds when cylnder pressure has fallen to bar whch leaves approxmately 10 mnutes supply of ar at moderate breathng rate before complete exhauston) The safe management of BA wearers n a rsk area s acheved by the strct adherence to the establshed procedures and by the ndvduals nvolved n the controllng support functons. Whlst the overall ncdent Commander carres ultmate responsblty for freground safety, the BAECO has some very specfc responsbltes n respect of hs/her dutes n the event of an emergency. The responsbltes, whch are defned n O&T Note A24, secton ncludes sendng the Emergency Team (f avalable) nto the rsk and mmedately nformng the Offcer-n-Charge n the event of any of the followng: f any wearer fals to return to the Entry Control Pont by the 'Tme of Whstle' f a Dstress Sgnal Unt (DSU) s heard to have operated f t appears that any BA wearer s n dstress f there s a sudden and unforeseeable breakdown n rado communcatons beng used by any BA wearer. The purpose of the Emergency T earn n such crcumstances would be to locate and recover the mssng team. (A Dstress Sgnal Unt (DSU) s an elecu'oncally operated devce attached to all BA sets whch becomes actvated when the tally s removed from the set and handed to the BAECO. n essence, the DSU montors the movement of the wearer, n the absence of whch t sounds a loud audble alarm sgnal after 101 ty seconds to rase the alert that a wearer s n dstress. The unt s also capable of beng operated manually by the wearer n the event of a stuaton causng dstress) On beng nformed of such a development, the Offcer-n-Charge must mmedately ntate a message to Brgade Control ncludng the words "Breathng Apparatus Page 37

44 General Breathng Apparatus Procedures Control Emergency". Should the Offcer-n-Charge not be mmedately avalable, the BAECO has the duty of ntatng such a message. n response to a BA Control Emergency, Brgade Control moblses automatcally, the followng support resources: (a) two addtonal fully crewed pumpng applances carryng BA "Each nstance should be subjected to a detaled nvestgaton n the lad down procedure to ascertan the cause" Secton of the O&T Note A24 (whch s also secton 32.4 of Techncal Bulletn 1189) states as follows: (b) (c) (d) (e) one rescue tender, f one S attendance not already n a thermal magng camera, f one s not already n attendance an ambulance the BA Servce Vehcle and supportng applance an addtonal Supervsory Offcer. "Where the Olfcer-n-Charge determnes that an ncdent should be treated as one whch requres nvestgaton, the followng procedures should be followed: (a) the apparatus, and any other relevant equpment and records should be mpounded; (b) the cylnder valve of the apparatus should be /dly closed and the number of turns requred to close t should be noted; 9.3 BA Emergency Whlst the rgorous and detaled nature of the procedures mplct n Techncal Bulletn 1189 are ntended to mnmse occurrences of dstress to wearer, such ncdents can and do occur from tme to tme whch make t necessary to have a predetermned BA Emergency Procedure. Not all ncdents causng dstress to a wearer requre mplementaton of the BA Emergency Procedure. n a stuaton where a relatvely mnor set defect arses - for example, a leakage of compressed ar whch does not prevent the wearer from takng the approprate acton and returnng mmedately to the Entry Control Pont unaded, the mplementaton of the. BA Emergency Procedure would clearly not be justfed. The dstnctons drawn between a serous, non-emergency stuaton such as ths and a genune emergency requrng urgent acton to retreve s not clearly made n ether the Techncal Bulletn, or the Brgade's O&T Note A24. nqures made of Brgade 'experts' n breathng apparatus produced a varety of nterpretatons whch confrmed the lack of clarty between 'wearer n dstress' stuatons and a 'BA Emergency' condton. Notwthstandng ths confuson over defntons, the Reportng of njures, Dseases and Dangerous Occurrences Regulatons 1985 (RDDOR) specfes that any ncdent where breathng apparatus or other apparatus servng the same purpose, whle beng used, fals to functon safely or develops a defect lkely to affect ts safe workng s a notfable 'Dangerous Occurrence' wthn the meanng of the Regulatons. All ncdents fallng wthn ths defnton are therefore potentally 'notfable' and treated from the outset of ther dscovery as though they were. Clarfcaton about whether a partcular ncdent s notfable or not s determned by the HSE and n antcpaton of the potental rulng of the HSE n the case of a mnor ncdent, the Offcer.n-Charge s requred to determne the level of nvestgaton launched n an endeavour to ascertan the cause of the ncdent. O&T Note A24, Secton states that (e) the apparatus s to be sent for specalst examnaton as soon as possble. t s the responsblty of the local Factory nspector to determne at what level the examnaton s to be carred out. The Factory nspector wll tell the Brgade whether the Brgade can carry out the examnaton, or whether the manufocturer shollld. t wll be up to the Brgade and the manufocturer to reach agreement on whether they carry out ths examnaton together. n certan more serolts cases, the Factory nspector wll decde that the set MUST be sent to HSE's laboratores. Untl the Factory nspector has made a decson, no Brgade personnel or manufocturers representatve should dsmantle the set". The correct gudance to be followed n the event of a 'notfable' occurrence nvolvng breathng apparatus has been dffcult to ascertan from the avalable polcy documentaton and establshng n what crcumstances and to what extent an nvestgaton should be launched has proved equally elusve. The way n whch an emergency breathng apparatus stuaton s classfed or dentfed would appear to affect the type of emergency recovery procedures mplemented. Ths arses n the absence of any clearly defned dstncton between 'urgent' emergency stuatons where a wearer n dstressng crcumstances requres assstance and a 'non-urgent' emergency stuaton where a malfuncton has arsen whch can be retreved wthout assstance. The lad down emergency procedures appear to be overshadowed by the reportng requrements under RDDOR rather than the recovery or safe wthdrawal of the dstressed wearer. Both are mportant needs whch appear to have become confused. 9.4 Use of Gude Lnes A 'gude lne' s the term used to descrbe a pece of fre servce equpment whch comprses a plated rope of hemp or synthetc materal approxmately 6 to 8mm n dameter whch s used n assocaton wth BA as a route Page 38

45 General Breathng Apparatus Procedures marker for BA wearers. Gude lnes are manufactured to a specfcaton 60 metre length and are nterwoven at ntervals of 2.5 metres wth a par of 'tabs' of dfferent lengths, one of whch s also knotted Gude lnes are used only on the nstructons of the Offcer-n-Charge as a means for a BA team to retrace ther steps to the entry pont and to enable subsequent teams readly to locate them or the scene of operatons. A gude lne s stowed n a contaner whch s attached to the wre harness on the wngs of the BA set beng worn by the team leader. As the team enter the rsk area havng secured the free end of the gude lne n fresh ar under the control of the BAECO at the entry pont, the lne pays out of the contaner and s perodcally ted-off at about wast heght onto sutable anchor ponts as the team penetrate nto the rsk area. Ths lne s known as the 'man' gude lne whch may be extended by attachng another to the end and contnung. A maxmum of two man gude lnes are permtted from each Entry Control Pont. The man gude lne once lad, acts as the central spne onto whch subsequent teams enterng the rsk area attach ther own 'personal' lnes to enable them to follow the same route. A dfferent route may be taken from the man gude lne by attachng a further gude lne to t should the area to be searched extend beyond the length of the personal lne. The attached gude lne then becomes known as a 'branch' lne of whch no more than four should be used from each Entry Control Pont. n the event of evacuaton from the rsk area becomng necessary, BA teams are able to follqw the gude lne feelng the tabs as they proceed whch ndcate the dfference between way n and way out. Page 39

46 10 Breathng Apparatus nvestgaton 10.1 General The nvestgaton nto the breathng apparatus aspects of the fatal ncdent were approached wth fastdous attenton to detal not only because there s a legal requrement to do so but also because the Brgade tself places the hghest prorty on the provson of the best qualty personal protecton equpment and procedures for ts frefghters. n an endeavour to establsh f any of these were flawed, the followng aspects were addressed whch are dscussed n ths secton: mplementaton of Emergency Procedures Reportng Requrements Examnaton of Sets and Equpment Personal Protecton ssues General Applcaton of BA Procedures Tranng and Competence Standards t s stressed that the prmary ssue under consderaton n ths part of the nvestgaton has been to establsh whether a malfuncton of any equpment or procedure contrbuted to the death of Frefghter Fleur Lombard. Of secondary mportance has been ssues of relatvely mnor devatons from lad down procedures whch although n themselves are mportant aspects and have been so dentfed, they are subordnate to the underlyng causes of the death mplementaton of Emergency Procedures Condtons n the fre began to deterorate at approxmately 1307 hours when flame ntensty and nose was wtnessed to have started to ncrease. Assstant Dvsonal Offcer 1 the Offcer-n-Charge, was also aware of worsenng condtons and as a result, he ntated the 'make-up' message requestng two further pumps and a hydraulc platform at 1311 hours. t was at 1310 hours when Team2 wthdrew and reported the deteroratng condtons nsde, that the evacuaton procedure was ntated as prevously descrbed n Paragraph At 1311 hours, the Emergency BA Team were nstructed to start up ther sets and at 1312 hours, the Assstant Dvsonal Offcer nstructed them to follow the gude lne whch had been lad to the left havng at that tme become aware that Frefghter 9 of Team 1 had wthdrawn wthout hs partner. At 1313 hours Assstant Dvsonal Offcer 1 nstructed Staton Offcer 1 to send the 'BA Emergency' message whch was transmtted at 1315 hours. The 'BA Emergency' message was therefore ntated at the earlest possble tme and was entrely consstent wth Brgade polcy. The response to the message by Brgade Control ntated the moblsaton of the addtonal resources outlned n Paragraph mmedately and was also entrely consstent wth Brgade polcy The mpoundng of breathng apparatus and ancllary equpment at an ncdent nvolvng wearer dstress s referred to n Techncal Bulletn 1/89, Secton 32 and that gudance s transcrbed verbatm n the Brgade's 0 & T Note A24 as Secton The 0 & T Note however, also contans the Brgade polcy concernng wearer dstress whch ncorporates addtonal gudance ssued by the Home Offce n 1991 under 'Dear Chef Offcer Letter' 5/ 1991 outlnng the reportng requrements under RD DOR. The Brgade polcy s attached to the Report as Appendx 4. The polcy states that the Offcer-n-Charge of the ncdent s responsble for ensurng that the BA set gvng rse to the emergency s mpounded. n the Leo's ncdent ths would not have been possble untl the mssng frefghter was located. t has been establshed from the statement of Frefghter 9 (paragraph ) that Frefghter Lombard's BA set fell away when Frefghter 9 pulled her back by the shoulders whlst affectng the ~esc~e. The remander of the set was as a consequence left n Stu where t had become detached. Although the locaton from whch the body was recovered together wth the remans of the BA set were preserved, t was some eghteen to twenty hours later, after the fre had been extngushed, that the set and ts remans were recovered from the scene. Frefghter Lombard's BA set had by that tme suffered severe fre damage before t was mpounded whch made subsequent examnatons of the set less meanngful The Brgade polcy outlned n 0 & T Note A24, Secton 24.32, paragraph (b) also stpulates that: "Brgade Control must mmedately be nformed of a 'dstress to wearer' and they n turn wll nform the approprate Supervso)) Offcer who wll be responsble for nvestgatng the crcllmstances surroundng the wearer's dstress and ) cportng them to the Dvsonal Commander, 'S' Dvson and enterng the ncdent on the MOBJO. t may be necessary for the nomnated Supervsory Offcer to attend at the ncdent or n the case of hosptalsaton, at the hosptal. He wll be responsble forfully nvestgatng the ncdent, ascertanngfrom medcal staff, the wearer's medcal condton and any smoke nhalaton as a result of the ncdent". The above polcy s repeated n the Brgade's Applance and Equpment Manual -A & E B7, 'Breathng Apparatus' whch s at varance to the 0 & T Note verson n so far as the Supervsory Offcer s concerned. The A & Everson stpulates n the second paragraph of (b) that: "t may be necessal) for a nomnated SupervsO) Offce; to attend at the ncdent and n the case of Page 40

47 ) j (~) (J () ~ hosptalsaton, a further Super7Jsory Offcer wll attend at the hosptal..... '": As stated n paragraph above however, Brgade Control responded to the "BA Emergency" message n the approprate manner and moblsed accordng to nstructons. The 'Supervsory Offcer' was an Assstant Dvsonal Offcer who reported n auendance at 1332 hours. The Assstant Dvsonal Offcer was aware that he had been moblsed as a result of a 'BA Emergency' message and ndeed, on hs arrval began to organse some addtonal BA wearers to assst wth the search for the mssng frefghter whom he beleved ntally had not at that tme been recovered. The Assstant Dvsonal Offcer was subsequently advsed of the recovered fatalty by the then Deputy Chef Fre Offcer and nstructed to releve Assstant Dvsonal Offcer 1 from hs operatonal role to enable hm to be wthdrawn from the freground. The nvestgatng responsbltes outlned above were therefore overlooked ntally although a Leadng Frefghter was later desgnated to mpound the BA Control Board from Entry Control Pont 2. By ths tme however, the BA talles had been removed from the board and reunted wth ther respectve sets. Also mpounded at the same tme was the BA set whch Frefghter 9 had been wearng. Hs personal frefghtng kt was also mpounded at a later stage The actual procedure for mpoundng equpment followng a 'BA Emergency' s somewhat vague n the Brgade's 0 & T Note and even the gudance that exsts depends upon the 'Supervsory Offcer' nomnated to take responsblty for the stuaton memorsng the procedure when t needs to be mplemented. No copy of the procedure or ade memore of ts contents s carred on any applance, ncludng the BA Servce Vehcle, whch s one of the addtonal resources moblsed to a 'BA Emergency'. Notwthstandng these crcumstances, the Assstant Dvsonal Offcer who was moblsed as the 'BA Emergency' Supervsory Offcer was n fact, one of the Brgade's most knowledgeable and experenced Offcers n BA. The wsdom of the decson taken by the Freground Commander to leave Frefghter Lombard's BA set n stu where t became detached whlst beng rescued, s not challenged on the bass that the rescue of one fatalty at that stage was consdered suffcent verfcaton of the hazardous condtons nsde the buldng. t was therefore entrely justfable that no further rsk to lfe should have been consdered by commung a recovery team purely for mpoundng purposes. The addtonal damage sustaned by the set after the fatalty was however, a dsadvantage to the nvestgaton process. Frefghter Lombard's fre helmet was never recovered, presumed to have been completely consumed n the fre after her recovery Also of sgnfcant dsadvantage to the nvestgaton process was the dsposal by Frenchay Hosptal, of the deceased frefghters protectve clothng remans. These could have provded nvaluable sources of evdence to corroborate the fndngs of the nvestgaton. Had a Brgade representatve attended at the hosptal at the tme Breathng Apparatus nvestgaton of admsson, such a catastrophe may have been avoded especally f such a requrement formed part of the mpoundng procedure. Fragments of the frefghtng tunc were recovered from the BA set remans whch were subjected to testng and are referred to n Paragraphs and Reportng Requrements n accordance wth the requrements of Regulaton 3(1) of the Reportng of njures, Dseases and Dangerous Occurrences Regulatons 1985, the Health and Safety Executve duty Offcer was notfed of the fatalty at 1513 hours on Sunday, 4th February 1996 by Brgade Control usng the emergency out-of-hours telephone number. Contact was made wth the local nspector of Factores, 1 on Monday, 5th February who was brefed about the crcumstances of the ncdent. The ntenton to ntate a full nternal nvestgaton was also dscussed and gudance was sought about the testng and examnaton of the mpounded equpment. Havng dscussed the Brgade's proposals about how the nvestgaton should proceed, the Health and Safety Executve n a letter dated 7 February 1996, expressed ts contentment for the Brgade to conduct ts own nvestgaton nto the crcumstances surroundng the accdent to Fleur Lombard. The Health and Safety Executve also specfed a number of ssues t requred addressng and these have been taken nto account durng the nvestgaton and responded to n ths Report. Plate 13: Showng the remans o/set No. 359 Page 41

48 Breathng Apparatus nvestgaton () (j (j () CJ o () (J (J () u Plate 14: Remans ofbackplate - Set No Health and Safety Executve Forms F2508 n respect of Frefghter Lombard and Frefghter 9 were completed n accordance wth requrements and submtted to the Health and Safety Executve on 7th February Examnaton of Sets and Equpment By agreement wth the Health and Safety Executve, all tests and examnatons of mpounded equpment were conducted wthn the Brgade, some of whch were supplemented by scentfc or expert apprasals by external sources. The Brgade's Techncal Resources Manager, Dvsonal Offcer 2 was desgnated wth the task of conductng ths aspect of the nvestgaton whch forms the bass of ths secton of the Report. The process began wth the recovery from the scene, of those tems of breathng apparatus equpment whch had not prevously been mpounded. Dvsonal Offcer 2 accompaned by a scenes of crme Offcer, a photographer and other Offcers vsted the ncdent on Monday 5th February 1996 to carry out an excavaton and recovery of the breathng apparatus set number 359, the set beng worn by Frefghter Fleur Lombard at the tme of her death. A full lst of all tems recovered, together wth a sketch plan of the postons and a full report on the results of the subsequent examnaton of the tems are attached to ths Report as Appendces S/a and sb. By reference to those Appendces t wll be noted that the examnaton of the remnants, whch was conducted on Wednesday, 7th February 1996, was n the presence of the followng representatves: Dvsonal Offcer Leadng Frefghter Leadng Frefghter Frefghter 15 Comp Rep 1 ADO Techncal Resources Manager BA Techncan BA Techncan Fre Brgades Unon BA Techncan Sales and Marketng Drector (BA Set Manufacturers) 'B' Dvson At the same tme as the above examnaton and n the presence of the same representatves, a full techncal examnaton was carred out on breathng apparatus set number 363 whch had been worn by Frefghter Lombard's colleague, Frefghter 9 at the tme of death. The full offcal reports of the examnatons of set numbers 359 and 363 are appended as Appendx sc and 51 d respectvely t wll be noted from the above reports that the combustble parts of breathng apparatus set 359 (Frefghter Lombard's) were severely damaged or destroyed n the fre whch provded nsuffcent evdence from the examnaton to conclude whether any fault or defect exsted at the tme of death. Conversely however, no evdence was revealed to suggest any set defect ether. The daly test was carred out by Frefghter Lombard at the commencement of the shft and sgned as satsfactory. The examnaton of set 363 proved satsfactory wth no defects revealed. Confrmaton of both test results was Comp Rep 1 provded by Sales and Marketng Drector of Sebe Gorman and Co Ltd, (the set manufacturers) n a letter dated 8th February 1996 and reproduced as Appendx 51 e to ths Report Personal Protecton ssues A Breathng Apparatus Sets Both set numbers 359 (Frefghter Lombard) and 363 (Frefghter 9 were to the same specfcaton havng been procured at the same tme and placed on the run at B6 Speedwell on 22nd December Both sets were part of a batch of 50 sets purchased n 1988 and were the most up to date models n servce n the Brgade. The remander of the Brgade's 228 breathng apparatus sets were purchased n All sets wthn the Brgade conformed to BS 4667: Part 2: 1974 although of dfferent manufacturers varants. The Brgade had no sets conformng to the current European Standard - EN 137 at the tme of preparng ths Report. The set specfcaton s as follows: Manufacturer: Type: Model: Brtsh Standard: Certfcate of Assurance: Sebe Gorman & Co Ltd Frefghter 2 Varant 01 BS 4667: Part 2: 1974 No SH/BA/10 Page 42

49 Cylnder: Descrpton: Standard Equpment: Addtonal Equpment: 2250 ltre capacty A self-contaned postve pressure open crcut set mounted wth a sngle cylnder on a lghtweght backplate wth two stage pressure reducton and full vstarama face mask. Ultra lghtweght Lght Alloy Steel Welded (LASW.1) or Lght Alloy Seamless Steel (LASS.1) cylnders. Dktron DSX 1000 Dstress Sgnal Unt Standard breathng apparatus tally SA Model 812 Torch Personal Lne n Standard Pouch Sonc Communcatons (nt) Lmted Breathng Apparatus nvestgaton Table 1 below summarses the results ndependent advce was sought from Sebe Gorman & Co Ltd, the set manufacturers, n respect of the thermal performance of the breathng apparatus harness and the ar supply hose ftted to the sets used by the Brgade. The harness normally comprses three components, beng the webbng, the paddng and the paddng cover although Avon specfes ts sets to be suppled wthout the paddng to facltate easer decontamnaton of the set should t become contamnated. Pror to the mplementaton of the current European Standard EN 137 n 1992, the requrements of BS 4667: Part 2: 1974 were the standards to whch the Brgade's breathng apparatus sets compled. n the Brtsh Standard, the webbng materal had a mnmum melt temperature of 225 ± 10 degrees C. n 1992, the EN 137 standard n respect of the harness changed the performance crtera to one whch requred a mnmum gnton temperature of 485 C but s self-extngushng, creatng a char whch provdes an addtonal protecton barrer for the fbres. n respect of the ar supply hose, the (ftted only to Set No 359) Rado Communcatons equpment for use wth Phllps Ex outer layer s of Neoprene (CR) whch has self PF 85 ntrnscally safe rado set wth ntegral Dktron mcrophone n face mask and 'press-to-talk' swtch. extngushng flame propertes. The hose was rated for normal operaton at contnuous temperatures of 100 C wth a capablty of normal operaton at ntermttent temperatures up to 130 C. As part of EN 137 and EN 138 Part 10 testng, the hose s subject to 950 C flame and The dsparty of damage sustaned by Frefghter radant heat tests. Lombard and Frefghter 9 and by ther breathng apparatus sets has prevously been dscussed n Paragraphs The foregong results would appear to confrm and of ths Report whch concluded that Frefghter Lombard was caught n the path of a 'local deepenng' of gases at flame temperature by vrtue of beng that the nylon body harness and the rubber head harness of Frefghter Lombard's breathng apparatus set would have faled, and furthermore, would have faled wthn 30 the closest to the wall whch Frefghter 9 avoded seconds, at temperatures of 1000 C. Smlarly, the fre because he was slghtly further away when the flash over tunc she was wearng would also have gnted n that same occurred. As a result, she suffered the full effects of the temperature range. Gven that the test results are a estmated 1000 C plus temperatures of those gases and reasonably accurate assessment of performance and that flames for a very short perod of a few seconds. n an endeavour to reconcle the behavour of the breathng Table 1 apparatus set components n temperatures of that magntude, some ad hoc tests were Test A Test B (Faled at 1000 C Source commssoned. Whlst not concluded under Sample 0C) test condtons prescrbed by any of the Brtsh Standards for the respectve components, Nylon Breathng Apparatus Body Harness Sec note (a) 260 C the tests were ordered to gve an ndcaton of the performance of components Rubber Head Harness - Type (A) See note (b) \30"C All gnted at excessve temperatures. The tests were carred out by Brstol Cty Councl's Sonc Communcaton Cable 160"C ""thn Scentfc Servces, (the County of Avon Scentfc Servces Department at the tme Sample of Fre Tunc Materal see note (c) 30 seconds the tests were conducted) whose full report Breathng Apparatus Ar Supply Hose see note (d) forms Appendx 6 of ths Report. To summarse ther report, two types of test Rubber Head Harness - Type (B) See note (b) 190"C were carred out, the frst (Test A) to test the falure temperature of the test samples whlst under tenson n an oven by gradually ncreasng the temperature and the second, (Test B) to expose the samples to a temperature source of 1000 C for a short perod to assess behavour. Notes: (a) The Brgade specfcaton excludes the padded sleeve. (b) The Type A harness was ftted to 1981 sets and the Type B to the 1988 suppled sel~. (c) Dd not fal up to 260 C (d) Appeared stable up to 260 C but became brttle. Page 43

50 Breathng Apparatus nvestgaton the Fre Research Staton estmate of the flashover temperatures beng n the regon of 1000 C s also reasonably accurate, t s not unrealstc to deduce that the breathng apparatus set beng worn by Frefghter Lombard would have faled her n less than half a mnute. n that tme, the rubber head harness (Type 'B' n ths case) would have severed allowng the face mask to fall away. The nylon body harness of the set would have behaved n a smlar way explanng why the breathng apparatus set fell off the deceased when Frefghter 9 pulled her back by the shoulders when effectng the rescue. Such a scenaro would be consstent wth the Pathologst's report (paragraph 7.2.3) whch concluded that the respratory system contaned a moderate amount of soot and that both lungs were oedematous, congested and focally haemorrhagc n'places wth extensve burns to the mouth and the tp of the tongue. Taken together, the evdence suggests that the respratory protecton of the breathng apparatus faled n the prevalng temperatures causng flame and hot gases to be nhaled. B Frefghtng Unform The followng table specfes the clothng known to have been worn by Frefghter Lombard at the tme of her death. The lst has been compled by what was known to be the standard ssue at the tme and by other evdental factors from photographs and recollectons of her colleagues. very latest standards n respect of flame spread and heat transfer. n general terms, these garments satsfed all requrements of the tests wth generous margns n excess The standard performance specfcatons n respect of frefghters protectve clothng are based on normal crtera n 'average' condtons whch form the benchmark of the standard. BS EN 366: (Protectve Clothng - Protecton aganst heat and fre - Method of test: evaluaton of materals and materal assembles when exposed to a source of radant heat) states n ts ntroducton: "..... ndustral workers or frefghters may be exposed to medum radaton ntenstes for relatvely short perods of tme or to hgh radaton ntenstes for very short perods of tme. n the latter case, the clothng materal may be changed or even destroyed. Therefore, n ths case, the materals for the protectve clothng should be tested at medum and hgh heat flux denstes". The performance standards of the fre tunc and overtrousers beng worn by Frefghter Lombard when tested n accordance wth BS EN 366: 1993 produced a heat transfer ndex (HT) of 43 seconds at a heat flux densty of 20 Kw/m 2 Ths standard ndcates the tme taken for the fabrc assembly to resst an external pressursed flame of 1000 C at the heat flux densty, to the pont at whch Garment Suppler Model Standard Date ssued Fre Tunc Brstol Unforms Ltd Nomex A Overtrousers Brstol Unforms Ltd Nomex A26': Fre Helmet ntegrated Systems F 500 BS Fre Boots Blythes FF 2000 A Fre Gloves Brstol Unforms Ltd 5543 Workng Rg Alexandra Workwear PS 25 Trousers 'T'Shrt Denne Proban Treated % cotton Table 2 Notes: 'f Overtrousers specfed to A26 by Brgade. + Gloves manufactured to Amercan NFPA 1973 (1988) standards n the absence of a Brtsh specfcaton. All tems of unform conformed to the relevant Brtsh Standards or later European Standards whch are gradually replacng them and to the current Home Offce specfcatons. The fre tunc "and overtrousers were manufactured n accordance wth BS EN 469: 1995 to the second degree burns occur whch s equvalent to a 'Medum' level performance as defned by the EN standard. The overtrousers are manufactured wth renforced nsulaton n the knee area whch, when tested under the same condtons produced an HT of 52 seconds at a heat flux densty of 80 K w/ m". n both cases, the mnmum levels of HT requred to meet the standard s 30 seconds Research was undertaken on behalf of the Central Fre Brgades Advsory Councl by the Fre Research and Development Group of the Home Offce Fre Expermental Unt enttled 'Measurements of the Frefghtng Page 44

51 Breathng Apparatus nvestgaton Envronment' n The Research Report (Number 61) detaled how the frefghtng envronment was measured to determne ts effect on frefghters and ther equpment. The report acknowledges the lmted extent of ts studes and ponts out that a major research project would be necessary to take account of the wder physcal, physologcal and psychologcal factors assocated wth such an envronment. However, the report defned four exposure condtons as follows: Routne Condtons Apply to most operatng condtons experenced by a frefghter whch wll nclude elevated temperatures but not drect thermal radaton from fres. The lmts proposed/or routne condtons are 25 mnutes at OO C and a thermal radaton lmt ofl Kw/m 2. Hazardous Condtons Apply where a frefghter would be expected to operate/or only a short perod n hgh temperatures n combnaton wth thermal radaton. The lmts proposed/or routne condtons are 1 mnute at 160 C and a thermal radaton lmt 0/4 K w/ m 2, damage or njury s lkely to result. Extreme Condtons - Typcally ths would nclude snatch rescue stuatons or, at worst, retreat from a flash over condton. Extreme condtons have been taken to be above 160 C and 4Xw/m 2. n the tests at ambent temperature, 10Kw/m2 was tolerated/or 1 mnute but damage was sustaned to equpment and these condtons would not be acceptable operatonally. t may be possble to tolerate a hgher value for a short tme but njury to the frefghter and damage to equpment would occur. Crtcal Condtons - These are condtons beyond the 235 C and 1 OK w/m z lmt/or extreme condtons and could be lfe threatenng. The frefghter would not be expected to operate n these condtons. The report does not conclude that the above condtons are defntve but advances them from ts study as proposals for further dscusson and elaboraton. They are ncluded n ths Report merely to provde an llustraton of the context n whch condtons can become ntolerable to frefghters and the lmtatons of desgn standards for protectve clothng The Breathng Apparatus nvestgaton Report nto the recovery of Frefghter Lombard's breathng apparatus set remans from the fre (Appendx 5/ a) ndcates that peces of her fre tunc were recovered from underneath the set ncludng the makers label overwrtten wth "Frefghter Lombard" whch s normally attached to the nner zp flap on the nsde of the garment at the lower hem level. Samples of these were passed to the manufacturers, Brstol Unforms Lmted who were nvted to comment. Comp Rep 2 the Manufacturng Drector s a natonal authorty on the Brtsh and EN standards and s a representatve of the ndustry n that feld. He commented as follows: "Havng vewed the (other) scraps 0/ clothng the thermal barrer and lnngs appear to have melted rather than burnt. They certanly dd not exhbt any sgns a/combuston. As a result a/ths observaton, t s apparent that the temperature on the nsde 0/ the frefghters jacket must have been between C for ths type 0/ damage to occur. Havng vewed the other tems 0/ equpment, feel that the temperature nvolved must have been well n excess 0/ OOO C for a very shart perod. My estmate would be between one mnute thrty seconds and three mnutes as the destructon 0/ ths type a/materal s dependent upon the tme versus temperature rato. n ths case, suspect that there 'was a short term exposure to massve levels 0/ heat combned wth an enormous amoun to/energy n the ncdent. All 0/ these observatons are based on my work on standards and testng on ths protectve clothng on such test apparatus as Du-Pant's Thermo man and are not as a result 0/ any scentfc analyss" Com Rep 2 expert observatons have been vewed wth a degree of reservaton because the fragments of clothng upon whch he commented were recovered from beneath the breathng apparatus set whch remaned n stu throughout the fre. However, the detachment of the makers labels and the peces of tunc whch were attached to the breathng apparatus set must obvously have become detached at the tme that Frefghter Lombard was recovered and the breathng apparatus set fell away whch has already been establshed was wthn mnutes. The majorty of recovered tems were excavated from underneath debrs whch had fallen onto the remans after the casualty was removed whch would have provded some protecton at floor level from the worst effects of the fre. The fact that the makers label remaned suffcently ntact to allow ts nformaton to be read clearly when recovered was confrmaton of ths. t s therefore qute Comp Rep 2 possble that the samples of tunc vewed by had not deterorated further n the fre after the rescue Parts of the same fre tunc samples were also sent for forensc analyss to determne whether alcohol from the sprts dsplay to the rght sde of the poston from whch Frefghter Lombard was recovered, may have had an effect. The samples analysed were all recovered from the fre scene on 5th February, the day followng the fatalty and were scentfcally examned for the presence of any flammable volatle materal by the Forensc Scence Servce at Chepstow, Gwent. The samples tested and the results were: Table 3 Fr.lgment of Clothng Sample Debrs (possble bee mask) Elbrc rcm.lms (possble fre tunc) Debrs.t floor level Ethanol Dctt',ctoo Eth.tnol Detected Edunol Detectet Etll.lnol Detected Result Page 45

52 Breathng Apparatus nvestgaton Frefghter 9 frefghtng kt was also mpounded and sent for smlar analyss by the Forensc Scence Servce whch produced the followng results: Table 4 Sample Outer clothng and helmet Boots and Leggngs Result No trace detected No trace detected Whlst ethanol was detected on the samples from Frefghter Lombard, t was not possble to determne when they were contamnated wth alcohol snce many of the sprt bottles from the dsplay stand would have broken durng the fre. t would be speculaton to conclude that any sprt had come nto contact wth Frefghter Lombard at the tme of the flashover thereby contrbutng to the fre damage to the unform snce t was not possble to determne whether the sprt came nto contact wth her before or after death occurred. The absence of any trace of alcohol on the clothng of Frefghter 9 adds further doubt to the theory gven that he was n physcal contact wth Frefghter Lombard at the moment flash over occurred and even after becomng separated from her by the blast, he was only 2-3 metres away. Whlst some bottles may well have expected to react wth explosve force n temperatures of 1000 C plus, f they had done so n the few seconds that those temperatures would have endured, t appears hghly lkely that Frefghter 9 clothng would have been wthn range also Forensc photographs of the deceased made avalable to the nvestgaton Team showed evdence of extremely hgh temperature exposure of the head and arms wthout any sgns of remanng protecton from ether the fre helmet or the tunc, whch were not n evdence. The worse effects of the temperature were apparent on the entre head and both arms, the rght arm (nearest to the wall of the asle) beng the most severe. The rght arm however, stll had attached, the dscernble remans of the fre glove. Also n evdence was the charred remans of what appeared to be the 'T' shrt sleeve on the upper arm and shoulder. Areas of the body whch had receved the greatest protecton were n the area of the upper torso whch had been covered by the 'T' shrt together wth the back area whch had been shelded by the breathng apparatus set back-plate. The lower torso and feet were less affected and the legs were le;s affected than the upper body although there were marks on both legs showng the creases and folds n the workng rg under trousers. There was generally less damage to the left sde of the body than the rght. Such evdence would further support the theores already advanced that the deceased was caught n the path of the 'local deepenng' resultng from a massve flashover generatng temperatures of over 1000 C at a heat flux of around lomw/m z. n these condtons, the desgn specfcaton of all tems of frefghtng unform beng worn at the tme were exceeded n the extre1!e General Applcaton of Breathng Apparatus Procedures As already stated n Paragraph above, the nvestgaton has been concerned prmarly wth the crcumstances surroundng and contrbutng to the death of Fleur Lombard. Durng the course of the nvestgaton, certan shortcomngs were dentfed n whch establshed breathng apparatus procedures were not strctly followed. None have been dentfed durng the course of the nqures whch could have been construed as havng a drect correlaton to the death. Nevertheless, t has been an ntegral part of the nqures to establsh whether any procedural omssons had any mpact on the crcumstances surroundng the death n accordance wth the Terms of Reference for the nvestgaton. n commentng on these matters however, the prevalng crcumstances were taken nto account, partcularly n the way these may have nfluenced command decsons and actons at the tme. Some of those crcumstances may be summarsed as follows: Four changes of command n the frst ten mnutes An nvolved fre n a large, open buldng Uncertanty about casualtes left n the buldng Extremely heavy smoke-loggng Rapdly deteroratng condtons t has been recognsed and acknowledged that operatonal decsons are taken on the bass of calculated, professonal judgements made n the prevalng crcumstances at the tme. These cannot always be reconstructed after the event n a way whch shows the mperatves perceved by those nvolved and no attempt has been made to do so n reportng the shortcomngs. The procedural omssons have been catalogued below as a matter of record from whch t s hoped, lessons may be learned for the beneft of future routne and compulsory breathng apparatus tranng. Some of the ssues are referred to agan n the conclusons Brefng The confuson that arose when Team 1 entered (Frefghters Lombard/ 9 about whether they were layng the gude lne and takng the hosereel and also between the two of them about the drecton they were supposed to be layng the gude lne should not have arsen f adequate brefng had been gven (Paragraph refers). Smlarly, the confuson between Teams 1 and 2 over ther respectve tasks whch led to the two teams becomng separated could also have been prevented by adequate brefng. (Paragraph refers). The two breathng apparatus teams who were operatng jets at the rear of the buldng from Entry Control Pont 1 n the rear car park were not brefed ether that other breathng apparatus teams were enterng the buldng on the opposte sde. t s not known to what ea1:ent, f any, the frefghtng jets contrbuted to the flashover condtons as dscussed n Paragraph (b) and ndeed, t never wll be known, but Page 46

53 Breathng Apparatus nvestgaton as a matter of good practcal fremanshp, the presence of other teams n the buldng would have been better known to those concerned Personal Lne Attachment Techncal Bulletn 1189, Secton 27(2) - (0 & T Note (2)) stpulates that "When a gude lne s beng lad, all members of the team other than the team leader are to attach themselves to the team member n front of them by the short length of personal lne". Frefghter 9 omtted to do ths n favour of mantanng close physcal contact wth Frefghter Lombard as stated n Paragraph Although techncally n breach of the gudance, the physcal contact between them served precsely the same purpose and had no detrmental effects on operatons. The rony of beng unconnected by personal lne leaves open the queston of the potental outcome of the flashover had they both been connected by 1.25 metres of lne Man Gude Lne Techncal Bulletn 1/89, Secton 26(8) (h) - 0 & T Note 24.26(8) (a)) stpulates that "When a team layng a gude lne has to retre before the objectve s reached, the team leader should ensure that the contaner s unfastened and secured at a convenent pont... etc". The omsson by Frefghter Lombard to detach the gude lne contaner gave rse to a lne of enqury to dscover whether the attached and tralng lne may have 'snagged' on the way out or whether the lne may have pad out completely, n ether case, preventng further progress. No evdence supported ether theory, n the frst case because she was stll n physcal contact wth Frefghter 9 who would have been aware of any mparment of progress, and n the second case, because there remaned approxmately 10 metres of un-used lne n the contaner whch was more than adequate to return to the Entry Control Pont. Whlst agan ths was a techncal breach of gudance, the condtons the team were experencng at the tme they decded to evacuate cannot be replcated and t s therefore completely understandable that nstncts of personal preservaton should take precedence over formal procedures Breathng Apparatus Emergency - Offcer Responsbltes Techncal Bulletn 1/89, Secton 32(4) (a) - (0 & T Note 24/ 32(4) (a)) places a specfc responsblty on the Offcer-n Charge of an ncdent n whch wearer dstress has occurred and where the Offcer determnes that an nvestgaton s requred, to mpound the apparatus, relevant equpment and records. These appear acceptable gudelnes to follow n a 'non-emergency' dstress to wearer stuaton - e one n whch a malfuncton arses whch n tself, does not prevent the wearer from mantanng respraton and retreatng to a place of safety. n an 'emergency' dstress to wearer stuaton however, - e one n whch a DSU has actvated or the wearer becomes the vctm of a lfe threatenng stuaton, the addtonal responsbltes can become an unwarranted addtonal burden at a tme when operatonal consderatons of the emergency stuaton tself are the man preoccupaton of the Offcer. The mpoundng of relevant equpment and collaton of evdence from the scene s consdered crucal f lessons are to be learned from a subsequent nvestgaton. An Offcer detached from the responsbltes of operatonal command wth clearly defned dutes and responsbltes followng an emergency breathng apparatus stuaton could have ensured that the approprate actons were ntated wthout delay. t may be that the Supervsory Offcer moblsed to an ncdent automatcally on recept of a 'Breathng Apparatus Emergency' message could fulfl ths role provded that the precse responsbltes were clearly defned and actoned. As already recorded n Paragraph 9.3.2, the current gudance s ambguous n respect of who s responsble for ntatng an nvestgaton followng a dstress to wearer and ndeed about whether an nvestgaton s necessary. Ths s further confused by the asserton that the Health and Safety Executve wll 'tell the Brgade' what, f any, nvestgaton s necessary under RDDOR. The fact that the Supervsory Offcer attendng the ncdent as a result of the 'Breathng Apparatus Emergency' was dverted to other dutes was an oversght whch could have prevented some of the procedural omssons Board Preservaton of Breathng Apparatus Control Wthn the same arena as the prevous paragraph, the lack of clarty by all concerned together wth the delay n mpoundng equpment ncludng the Breathng Apparatus Control Board mmedately followng the 'Breathng Apparatus Emergency' resulted n some breathng apparatus talles havng been removed. Ths was an oversght whch could have been avoded by mproved famlarty wth the emergency procedures. Fortunately such emergency stuatons are rare occurrences and the oversghts can be understood, partcularly n such harrowng crcumstances as ths ncdent Supervson of Casualty Whlst not strctly a part of the breathng apparatus procedure, the supervson of the casualty was a sgnfcant ssue n ths case and therefore warrants comment. As prevously mentoned n Paragraph , Frefghter Lombard's frefghtng unform was dsposed of at the hosptal she was taken to whch destroyed potental sources of valuable evdence. As no formal Brgade procedure exsts n respect of these crcumstances, no breach occurred but t was consdered a serous oversght not to have had a Brgade Offcer accompany the casualty to hosptal as a matter of course and a dstnct set back not to have recovered the personal protectve clothng from the deceased Breathng Apparatus Entry Control Procedures As already stated, the mpounded Breathng Apparatus Control Board used at Entry Control Pont 2 contaned no Page 47

54 Breathng Apparatus nvestgaton talles. The deductons and conclusons of the breathng apparatus nvestgaton therefore had to rely on a reconstructon based on the evdence avalable. The oversght of ths aspect appeared to be part of the general evdence of an neffectve mpoundng procedure. The BAECO at Entry Control Pont 2 undertook the essental elements of hs responsbltes extremely well n that he followed correct procedures on recevng the talles from wearers, he completed all crucal nformaton and he arranged an emergency breathng apparatus team at the earlest opportunty. He also acted approprately when the Breathng Apparatus Emergency was declared by assstng wth the deployment of the emergency team and ntatng the evacuaton sgnals. The BAECO dd not appear to be formally brefed about the tasks beng performed by the breathng apparatus teams and t appears that the nformaton he dd glean was concdental rather than ntentonal. Had ths been the case, better nformaton may have been recorded on the breathng apparatus board related to both ntal breathng apparatus teams n respect of ther tasks and purpose. The use of the hosereel by Team 2 was recorded as beng used by Team 1 and the use of an astersk to ndcate the lowest cylnder pressure of the team was only used for Teams 1 and 2. Where the set numbers were over-wrtten onto the board, one set, number 348, had been entered n two dfferent places where one should have been 343. An llustraton of the reconstructed Breathng Apparatus Control Board s ncluded as Appendx Tranng and Competence Standards General The nvestgaton nto ths ncdent embraced tranng and the standards of competency nsofar as te key ndvduals were concerned for two basc reasons: To dentfy any Brgade practces and procedures whch may need to be revewed n lne wth the terms of reference for the nvestgaton, and To address specfc questons about trammg generally rased by the Health and Safety Executve (HSE). Tranng for Brtsh fre servce members s a statutory requrement of fre authortes as prescrbed n Secton l(l)(b) of the Fre Servces Act 1947 whch states: '1(1) t shall be the duty of every fre authorty n Great Brtan to make provson for fre fghtng prnposes, and n partcular every fre allthorty shall secure (aj-.... (b) the effcent tranng of the members of the fre brgade'. The Jont Tranng Commttee ate) s a statutory body wthn the Central Fre Brgades Advsory Councl establshed by the Secretary of State under Secton 29 of the Act to advse hm on tranng matters upon whch he may make regulatons to secure effcent fre servces. Appontments and recrut tranng are covered by such regulatons whch apply natonally and set the crtera for the physcal standards for recrutment and the standards of recrut trammg. Certan other aspects of tranng are undertaken to natonal standards of gudance where brgades have some jursdcton as to how the gudance s compled wth. nsofar as ths nvestgaton has been concerned, the followng aspects of operatonal tranng have been examned n respect of the ndvduals concerned, where applcable. (a) Recrut Tranng (b) Probatonary Tranng (c) Statutory Tranng (d) Routne Tranng (e) Specalst Tranng (D Core Progressonal Tranng The ndvduals upon whom the examnaton has been focused were the four freground command Offcers and the two members of breathng apparatus Team 1 - Frefghters Lombard and 9 Only ssues consdered to have a potental relevance to the reasons gven above are referred to n ths secton. The prncpal ams of ths part of the nvestgaton were to examne the tranng receved by the ndvduals concerned partcularly n respect of breathng apparatus tranng and tranng for ths type of rsk to assess the adequacy or otherwse of preparedness for the stuaton wth whch they were confronted n ths ncdent Recrut Tranng Formal, structured recrut tranng s oblgatory for all new recruts to the operatonal fre servce before operatonal engagement. The basc tranng course for wholetme recruts s provded n accordance wth a natonal syllabus set by the Jont Tranng Commttee of the CFBAC and authorsed by the Secretary of State. The course embraces a range of basc subjects delvered through both techncal and practcal nput totallng a mnmum of 450 hours over a 12/13 week course. n addton, dedcated tranng n the practce and theory of breathng apparatus s an ntegral part of the recrut tranng over a further two week course whch s usually durng the mddle or latter part of t he course. Practcal tranng usng breathng apparatus s ntegrated wth other practcal fremanshp sklls qute extensvely throughout the course. Recrut tranng courses are run n-house by a number of brgades, some of whch also make places avalable to other brgades on a feepayng bass. Wth a throughput of about 40 recruts per year, Avon has tradtonally traned ts own recruts at the Brgade Tranng School snce ts ncepton n Recrut Tranng was suspended however, n 1990 when for budgetary reasons, Avon's recruts were traned by Hampshre Fre Brgade. Ths ceased n 1993 when nhouse recrut tranng was re-n stated. The course on Page 48

55 Breathng Apparatus nvestgaton whch Fleur Lombard was traned -Recruts Course R 4/93, was the frst course run at the Brgade Tranng School after renstatement. Valdaton of tranng for recruts n Avon s by contnual assessment n three key result areas - practcal, wrtten and oral competences. These are assessed by examnatons at md-course and end of course and through weekly montorng by nstructors. Total marks are aggregated to determne fnal results wth a mnmum pass mark of 70%. The breathng apparatus course s assessed n the same way but on a stand-alone bass whch s not aggregated nto the recruts course marks. t s Brgade polcy that recruts must pass the breathng apparatus course to qualfy at the end of recrut tranng. Falure to acheve a pass n breathng apparatus results n overall falure of the course. t s a matter of record that Frefghter Fleur Lombard acheved top marks on her course of 18 qualfers and was awarded frst place together wth the coveted 'Slver Axe' award for most outstandng recrut of the course Probatonary Tranng Appontment as a frefghter s subject to a term of probatonary servce of not less than twelve months or more than two years n accordance wth the Natonal Jont Councl for Local Authortes Fre Brgades - Scheme of Condtons of Servce. t s the polcy of Avon Fre Brgade that the probatonary term shall be two years from the date of appontment, ncludng the recruts tranng course (15 weeks). At the commencement of the probatonary term mmedately followng successful completon of recrut tranng, all recruts are assgned to operatonal dutes alongsde qualfed frefghter colleagues on the 'watch' to whch they are posted. They mmedately become drectly accountable to the Offcer-n-Charge of the watch and also become subject to the Brgade's Probatonary Tranng Scheme (PTS). Although the PTS has been revsed snce Frefghter Lombard undertook her probatonary tranng, the purpose of the scheme remans, - as a structured, progressonal contnuaton tranng regme ntended to complement and enhance recrut tranng to ensure that the basc sklls learned are refned to the level of competence requred of an effcent, effectve and safe member of a frefghtng team. n ts entrety, the scheme s a complete programme of prvate study (of Manuals of Fremanshp, Brgade polcy notes, techncal publcatons etc), formal tranng and experental development dvded nto four equal phases of approxmately eghteen weeks each. The scheme ncorporated the followng features durng Frefghter Lombard's probatonary term (some of whch have snce been revsed): Probatonary Self-Study Syllabus Staton Drected Study Syllabus Staton Montor Reports Dvsonal Montor Reports Courses and Examnatons Probatonary Dary Progressve Montorng Through a combnaton of these features, the PTS provded the means for progressonal tranng and the methods by whch achevement was montored to assess both performance standards and development needs throughout the probatonary term. Competence was assessed by a detaled measure of performance n four key result areas smlar to the recrut tranng standards - of practcal examnatons, wrtten examnatons and oral examnatons. Also ncluded was the results of an objectvely based montorng system at both staton and dvsonal level to provde a personal dmenson to the more formalsed assessments wth the purpose of brngng balance to the overall performance standards by ncludng a measure of 'on-the-job' apprasal. Formal examnatons were taken at the end of each phase whch concded wth a one-week end of phase course at the Brgade Tranng School n whch advanced group tranng was provded along wth specal rsk vsts, famlarsaton wth specalst applances and equpment and specalsed subject nput. Such tranng was drectly lnked to the probatoner's 'Self-Study' and 'Staton Drected' Syllab n the prevous phase to consoldate the study undertaken. Performance throughout the PTS was montored by a combnaton of end-ofphase examnaton results and staton and dvsonal montor marks. To allow for fluctuatons n sklls levels amongst ndvduals, where for example, a female frefghter could be dsadvantaged by a male frefghter on grounds of physcal strength or where ndvduals had opposng levels of achevement between practcal and academc sklls, all marks were computed to moderate results and produce a measure of achevement called a 'credt ratng'. A total of 200 credts were avalable'over the whole of the PTS, 50 n each phase. A mnmum of 35 (70%) were requred for success n each phase although a weakness n one area could be retreved n the next phase by a strength n another. The maxmum number of credts avalable n each of the key result areas was weghted to reflect the sklls expectatons of an operatonal frefghter llustrated n the followng table: Table 5 Credts per Phase Key Result Area Max Mn Practcal Wrtten Oral Montor Reports 10 7 Totals At the completon of Phase 1 of her PTS, Frefghter Lombard acheved a total credt ratng of reflectng her contnung hgh levels of commtment and achevement. After Phase 1, the credt ratng system was dscontnued however, n favour of a reportng mechansm whch no longer assessed personal levels of attanment n separate areas of objectve performance but adopted Page 49

56 Breathng Apparatus nvestgaton nstead, a 'satsfactory' or 'unsatsfactory' assessment crtera. Other revsons to the PTS have also been ntroduced ncludng very recently, a reducton n end of phase courses from four to two on the grounds of low rdershp factors - e a shortfall of resources to mantan operatonal crewng levels. n response to a demand by brgades, the Fre Servce College developed a Realstc Fre Tranng Course (RFT) n 1993 of two days duraton for both probatonary and qualfed frefghters. The course amed to provde maxmum exposure to heat, smoke and varyng fre condtons and ther bearng on physology, frefghtng and rescue technques and crew safety. The course objectves were to provde students wth experence of the effects of heat and humdty on the human body and to gan a better understandng of the need to conserve and replace energy. n addton, students would receve practcal nstructon, under realstc condtons, n movement n heat and smoke and wtness the buld-up and mushroomng effects of smoke wthn buldngs. nstructon was also gven n frefghtng and rescue procedures n real fre condtons n both domestc and mult storey propertes together wth experence of layng, extendng and followng man and branch gudelnes n a large complex buldng n real fre condtons. Although the course became avalable whlst Frefghter Lombard was n the recrut tranng and probatonary perod, suffcent funds were not avalable n the tranng budget at the tme to resource such tranng. Frefghter 9 receved hs recrut tranng at Devon Fre and Rescue Servce and dd attend the RFT course whlst a Probatonary frefghter wth Somerset Statutory Tranng Statutory tranng s that whch s requred as a mnmum level over a perod of tme to satsfy ether natonal (Home Offce) standards or local (Brgade) polces. nsofar as breathng apparatus tranng s concerned, the mnmum requrements are establshed by the CFBAC and are commended to fre authortes n Fre Servce Crcular 17/ 'Breathng Apparatus - Basc Tranng of Wholetme Men'. The gudance also recommends that all breathng apparatus wearers attend. a 2/3 day refresher course at 2 yearly ntervals and f breathng apparatus has not been worn at a fre durng any perod of 12 months, the refresher tranng should be n heat and smoke. The Brgade satsfes that recommendaton by provdng a centralsed, one-day refresher course per year comprsng approxmately 50% practcal workng n heat and smoke and 50% theoretcal nput all delvered by fully qualfed breathng apparatus nstructors at the Brgade Tranng School. Targetng all Brgade members for breathng apparatus refresher tranng s a resource ntensve programme whch s further constraned by the exstence of only one breathng apparatus tranng faclty sutable for smoke combned wth background heatng whch s approprately equpped wth the necessary smoke extracton equpment for emergency stuatons. The poston s further compounded by the Routne Tranng needs of all operatonal frefghters (see Paragraph below) to fulfl ther essental breathng apparatus wearng drlls n heat and smoke whch can only be undertaken n the same faclty. The Brgade has no faclty for realstc fre tranng nvolvng real fre condtons whch requres a specalst trammg envronment. Nether has the Brgade any realstc smulaton tranng technology whch s currently avalable n the market for both these and command and control tranng scenaros Routne Tranng Routne tranng, also known as operatonal tranng, s ntended to develop and mantan general competence amongst all operatonal frefghters by practsng sklls and procedures and by revsng polces and nstructons on an ongong bass at staton level. One and a half hours are allocated n each workng shft (except publc holdays and week-end nghts) durng whch watch offcers provde the nput to a pre-determned programme of planned, structured tranng, at least 30 mnutes of whch s devoted to basc practcal sklls. The tranng receved by each ndvdual (and ndeed absences from tranng) are recorded n coded form on a Personal Tranng Record mantaned at staton level n respect of all operatonal personnel. The codes relate to specfc drlls or procedures detaled n the Fre Servce Drll Book (now Tranng Manual) or other recognsed publcatons, some of whch are referred to as 'Essental Drlls'. The wearng of breathng apparatus s ncluded n the 'Essental Drlls' category whereby all wearers must wear breathng apparatus a mnmum of fve tmes per year n smoke, and n addton, once per year n heat and smoke. These essental breathng apparatus drlls are n addton to any occasons when breathng apparatus s worn operatonally at an ncdent whch are also recorded on the Personal Tranng Record. The pre-determned programme of routne tranng s devsed by the watch Offcern-Charge who determnes the ndvdual tranng needs of hs watch from personal knowledge of ndvduals. Such a programme also ncludes rsk vsts and lectures gven on specfc subjects. n decdng the tranng needs of hs watch members, an Offcer-n-Charge has to have regard to the provson of a balanced programme of tranng durng the course of a year as well as completon of the essental drlls whch the Personal Tranng Record provdes an overvew for. The presence on the watch of a probatonary frefghter wll also nfluence the routne tranng programme because of the staton drected tranng syllabus to whch he/she s subjected. Ths syllabus often provdes a focus for the structure of routne tranng to the wder beneft of all watch members by revsng basc development sklls. The valdaton of routne tranng s acheved through b-monthly watch nspectons by Dvsonal Supervsory Offcers durng whch basc sklls are tested by observng drlls, records are nspected and general standards of upkeep are checked. Personal Tranng Records are nspected to ensure that all essental and statutory drlls are beng carred out, that all personnel are attendng for tranng and that a balanced progr,lmme s Page 50

57 Breathng Apparatus nvestgaton beng mantaned. Any dscrepances found become the subject of a plan of acton between the Supervsory Offcer and the Offcer-n-Charge. The Personal Tranng Record of Frefghter Lombard for 1995 recorded the followng relevant detals n respect of breathng apparatus. Tranng Receved No of occasons Essental breathng apparatus n smoke 7 Essental breathng apparatus n heat and smoke 1 Routne breathng apparatus usng gudelne/ personal lne 7 Routne breathng apparatus emergency procedures 4 Routne breathng apparatus usng search! rescue technques 6 Routne breathng apparatus communcatons equpment 1 Routne breathng apparatus nvolvng decontamnaton! radaton 1 Breathng apparatus set servcng Breathng apparatus set testng Breathng apparatus Stage BA Control Breathng apparatus Stage BA Control n addton, sx occasons were recorded on whch Frefghter Lombard wore breathng apparatus at an ncdent durng the same perod Specalst Tranng Specalst tranng n ths context s the term used to descrbe formal, structured tranng n a course or semnar format desgned to meet specfc tranng needs. t can be provded ether nternally or externally (whch would usually be the Fre Servce College) and may be complmentary to core progressonal tranng (see below). A number of courses are provded nternally whch fall nto ths category, none of them relevant to the nvestgaton. Smlarly, some of the ndvduals referred to n Paragraph above, have attended specalst tranng courses both nternally and externally, but agan, none of these are relevant to the nvestgaton Core Progressonal Tranng Core progressonal tranng descrbes the structured progressve tranng provded to all Offcers n the Brtsh fre servce by the natonal Fre Servce College. Although several changes have been made n ntervenng years, the orgnal concept of progressve tranng was devsed and approved by the CFBAC n Specfc courses were desgned and targeted at junor command, staton command, dvsonal command and brgade command but n 1992, a Tranng Strategy Group (TSG) was formed to analyse the selecton, tranng and development needs of the fre servce both long and short term, to dentfy the problems and make proposals for acton. n ts report publshed n 1994, the TSG recognsed, n respect of core progressonal tranng, that gaps exsted n the tranng avalable between staton and dvsonal command, and recommended a restructurng of the progressonal tranng provded. As a result a new course for 'crew commander' was ntroduced and the ntermedate command courses were proposed for re-defnton to brdge the perceved gaps. The syllabus for each of the courses ams to equp ts students wth the operatonal command and control, and management sklls approprate to the dfferent levels of responsblty on a progressve bass from the most junorcrew commander, through to the most senor - brgade command. Pror to the TSG recommended changes, the prevous core progressonal courses were the Junor Offcers Course GO) for Leadng Frefghters and Sub Offcers n ther frst supervsory role, the Junor Offcers Advancement Course GOA) for Sub Offcers and Staton Offcers wth Watch or Staton Command responsbltes, the Dvsonal Command Course (DCC) for Offcers wth dvsonal command responsbltes and the Brgade Command Course (BCC) entry to whch s by selecton only. As a result of the TSG report, the JO course has been replaced by the two new role orentated courses; Crew Command Course (CCC) and Watch Commanders Course (WCC). TheJOA course remans at present largely n ts orgnal format but wth sgnfcant revson to the content and coverage. Student valdaton for all courses s by assessment and to gan accredtaton of the course, students must pass all assessments. Core progresson tranng s compulsory for all Offcers n Avon and attendance on desgnated tranng courses of all descrptons s a condton of appontment. None of the Offcers attendng the Leos ncdent who were referred to n Paragraph above had been a student on the new format courses at the Fre Servce College - e CCC and WCe. A full breakdown of tranng receved by the relevant Offcers s provded n Table Tranng n the Phenomenon of Flashovers Snce the asserton made n ths Report s that Fleur Lombard ded as a result of the effects of a 'flashover', specfc tranng n the subject was a focus of the nvestgaton to ascertan what conclusons could be drawn. The terms 'flashover' and 'backdraught' have become common doms of fre servce language over recent years to descrbe phenomena n buldng fres whch had not prevously been wdely recognsed. Ongong research nto the phenomena contnues to produce new scentfc evdence to assst the frefghter's knowledge, understandng and recognton of the symptoms. The condtons gvng rse to a flashover were formerly assocated wth the subject of ventlaton n fres whch was covered n earler Manuals of Fremanshp and formed the bass of frefghter tranng on the subject. A 'flashover' condton was taught as one whch could be reduced or avoded by the approprate management of ventlaton. Later research has shown that the behavour of fre n a compartment cannot be predcted or controlled smply by ventlaton. n 1992, the CFBACJont Commttee on Fre Brgade Operatons requested a study nto what was known about flashovers and backdraughts, and the Fre Expermental Unt of the Home Offce Fre Research and Development Group undertook the work. Ther conclusons suggested that, whlst there were a number of areas where more research could be of beneft, a sgnfcant problem appeared to be a lack of effectve communcaton between fre scentsts and the fre servce, to enable Page 51

58 Breathng Apparatus nvestgaton frefghters to have beneft of the knowledge that s avalable. n 1995, the Home Offce publshed a supplement to Manuals of Fremanshp Books 1 and 11 enttled: "The Behavour of Fre - Compartment Fres". Ths supplement was an attempt to address what frefghters needed to know about compartment fres by summarsng what s understood about the early stages n the growth of a fre n a compartment leadng to a flash over and possble backdraught, and the effect of ventlaton. The followng defntons were publshed n the supplement: (a) Backdraught "Lmted ventlaton can lead to a fre n a compartment producng fre gases contanng sgnfcant proportons of partal combuston products and un-burnt pyrolyss products. f these accumulate then the admsson of ar when an openng s made to the compartment can lead to a sudden deflagraton. Ths deflagraton movng through the compartment and out of the openng s a backdraught". (b) Flashover "n a compartment fre there can come a stage where the total thermal radaton from the fre plume, hot gases and hot compartment boundares causes the radatve gnton of all exposed combustble surfaces wthn the compartment. Ths sudden and sustaned transton of a growng fre to a fully developed fre s a flashover'~ The latest nformaton on the subject avalable from the supplement was ntegrated nto the syllab at the Fre Servce College for the CCC, WCC and JOA courses n early 1994 (on the bass of advanced knowledge of ts contents) and was therefore taught on those courses. The recrut tranng syllabus n Avon was also revsed followng ts publcaton to ncorporate the subject nto the practcal fremanshp studes of recruts. None of the tranng undertaken by the four Offcers and two frefghters concerned had therefore ncluded the latest avalable nformaton on the subject. t was not possble to establsh whether the contents of the 'Compartment Fres' supplement nfluenced the routne tranng programme snce no formal gudance appeared to have been offered by the Brgade n respect of any drect acton whch mght have been taken by operatonal Offcers-n-Charge on recevng the new supplement. Ths problem has been recognsed by the Brgade and approprate acton has been taken to prevent a recurrence. The ongong research nto these phenomena contnues and fnal research results may not be avalable for another two to three years. The Home Offce have contnued to publsh new experence and nformaton n ths feld and as recently as July 1996, a further supplement to exstng Manuals of Fremanshp was publshed enttled 'The Behavour of Fre - Tactcal Ventlaton of Buldngs and Structures'. The document renforces and elaborates on the exstng gudance avalable n Book 12 of the Manuals of Fremanshp to whch t relates the latest advce and experence on the matter_ Rsk Famlarsaton Fre authortes have a duty under Secton l(l)(d) of the Fre Servces Act 1947 to: "Secure effcent arrangements for obtanng by nspecton or otherwse, nformaton requred for fre fghtng purposes wth respect to the character of the buldngs and other property n the area of the fre authorty, the avalable water supples and the means 0/ access thereto, and other materal local crcumstances ': n Avon Fre Brgade, ths duty s fulflled n the man, through the staton routne tranng programme by the watch Offcers-n-Charge plannng 1 (1) (d) vsts n advance. Untl 1991, premses dentfed as a 'specal rsk' were the subject of an nformaton card (Gen 3) whch contaned detaled nformaton about the premse, the hazards, and other relevant nformaton whch were carred on applances on the pre-determned attendance to that rsk. The system fell nto dsrepute because of the dffculty n mantanng accurate and up-to-date nformaton wth the avalable resources. A new system was devsed as a consequence whch was ntended to substantally reduce the overall number of premses subject to a Gen.3 by redefnng the parameters of premses to whch t appled. The new system was devsed n 1992 and enttled the "jazardous Premses Card" scheme whch smplfed and streamlned the former Gen.3 system_ Although a number of surveys were carred out on premses to generate the Hazardous Premses Cards, they were not ssued. The 'new' system was postponed pendng the mplcatons of the Management of Health and Safety at Work Regulatons 1992 (MHSWR) whch prompted natonal debates about how the fre servce would satsfy those Regulatons. Leo's Supermarket at Staple Hll would not have fallen wthn the defnton of ether a 'specal rsk' or a 'hazardous premse' under ether scheme and would not therefore have been a subject of recorded rsk nformaton. Nether would Leo's have been consdered a partcularly hgh or specal rsk whch would have warranted a rsk famlarsaton vst under l(l)(d) of the Act. No specfc nformaton or knowledge about Leos would therefore have been avalable to the crews attendng the ncdent other than what mght have been known fortutously. As a 'certfcated' premse, the Brgade were however aware of ts exstence and held a fle contanng plans and fre safety correspondence at ts Area Fre Safety Headquarters. Nothng contaned wthn that fle was consdered of suffcently sgnfcant mportance operatonally as to warrant specal notfcaton to local frefghtng crews although facltes exst wthn the Brgade to do so n approprate cases. Certan categores of 'certfcated' and 'sleepng rsk' premses are regularly nspected by operatonal crews to ensure that the condtons of the fre Page 52

59 Breathng Apparatus nvestgaton certfcate are beng mantaned. The types of premse fallng wthn such categores nclude hotels, boardng houses, elderly persons homes, nsttutonal care establshments and certan small hosptals. Re-nspecton of these premses s carred out annually on a programmed bass so that each of the four watches at a staton vst once every four years. Ths ensures that all personnel have an opportunty to vst the premse whch has the added bonus of servng as a rsk famlarsaton vst at the same tme. Operatonal personnel also have other fre safety commtments whch provde exposure and famlarsaton wth rsks n ther area by undertakng nspectons at lcensed petroleum stes and premses applyng for regstraton under the Nurseres and Chldmnders Regulatons. Secton 1 (1) (d) nspectons carred out outsde these parameters are arranged totally at the dscreton of the watch Offcer-n-Charge. nsofar as the rsk assessment aspect of the Management of Health and Safety at Work Regulatons are concerned, the Brgade made a conscous decson at the begnnng of 1995 to launch a new health and safety ntatve. A new team was created specfcally to address tself to rsk assessment and general 'good practce' ntatves. Because natonal gudance was stll forthcomng at that tme, a postve decson was taken to postpone the development of a Brgade rsk assessment system pendng avalablty of the gudance. n the meantme, the Brgade ntated Health and Safety Awarene?s courses for Brgade managers n October 1995 whch was followed, n January 1996 wth the frst of a smlar seres of courses amed at watch commanders. Both courses ncluded nput on rsk assessment phlosophy and practce. The 'Gudance on the Applcaton of Rsk Assessment n the Fre Servce' was publshed n February 1996 as a result of whch a sub-commttee of the Brgade Safety Polcy Management Team was establshed specfcally to address operatonal! dynamc rsk assessment procedures. The subcommttee has the task of formulatng an operatonal rsk assessment procedure based on both the natonal gudance and the dverse experences of other Brgades that have already trodden the path. The work of the sub-commttee contnues as ths Report s prepared. Page 53

60 Synopss of Tranng Receved Date of Appontment Recrut Tranng Complete Probatonary Realstc Fre Junor Offcers Tranng Tranng Course Complete (RFT) GO) Junor Offcer Advancement GOA) ADO 1 26/3/ /6/1970 (Surrey) 26/3/1972 N/A 25/ / StnO 1 (a) 6/1/ (Surrey) 22/4/1988 N/A Yes Unknown) (Date Yes Unknown) (Date SubO 11 (b) 31/8/ / /8/1968 N/A 9/ N/A SubO 2 (c) 6/ /1982 6/9/1984 N/A 10112/1993 (c) N/A Ff 9 d) 6/1/ /4/1992 (Devon) 14/6/ (Somerset) N/A N/A Ff F Lombard (c) 1/11/ / No N/A N/A Notes: (a) Staton Offcer 1 transferred to Avon from Surrey Fre llrgade on Personal Tranng Records were not transferred (h) Sub Offcer l1 joned as a Junor Freman aged 16 (c) Sub Offcer 2 attended d,e Watch Comnmlders Course (WCC) whch superseded the JO (d) Frefghter 9 transferred to Avon from Somerset Fre llrgade on 16/ Personal Tranng Rrecords were not transferred (e) Frefghter Lombard prevously served as a retaned frefghter (October November 1993) at Derbyshre Fre Servce pror to commencng her wholetme appontment n November 1993 Table 6 "'Cl PJ fjo (J) v,..j::..

61 11 Personal Profle -Frefghter Fleur Lombard (Deceased) 11.1 Status Name Fleur Lombard Age 21 years Date of Brth 27 May 1974 Martal Status Sngle Date of Appontment 1 November Educatonal Qualfcatons 'A'Levels 3 - (Englsh Language, General Studes and Socology) GCSE's 9 - (Englsh Language, Englsh Lterature, Maths, Hstory, Art, Socology, Physcs, Bology, German) 11.3 Professonal Qualfcatons Slver Axe Award Wnner for top recrut on course Compressed ar breathng apparatus operator St John's Ambulance Frst Ad Certfcate Leadng Frefghters Examnaton - Part 11.4 Prevous Employment Retaned Frefghter - Derbyshre Fre Servce (Whaley Brdge Staton) October 1992 to October 1993 Voluntary Shop Assstant (Saturdays) - Help the Aged Charty Shop Sprng 1992 Watress (Saturdays) - 'Dandelon Days'. Vegetaran Restaurant January 1992 to May 1992 Personal Assstant/Assstant Conference Organser - Joyce McLellan Conferences June 1992 to October 1992 Full-tme Voluntary School Assstant - Derbyshre County Councl Educaton Department February 1993 to October 1993 Lesure Actvtes Runnng Weght Tranng Aerobcs Mountan Bkng Swmmng Restoraton of MG Mdget motor car Page 55

62 12 Conclusons and Recommendatons 12.1 General The conclusons have been prmarly motvated by the Terms of Reference for the nvestgaton whch were detaled n Paragraph The Report htherto has recorded all materal facts revealed by the nvestgaton together wth the relevant polces, practces, procedures and standards whch dd or should have appled. n addton to establshng the crcumstances surroundng the death of Frefghter Fleur Lombard, all other matters referred to n ths Report have been the subject of nvestgaton n an endeavour to dentfy contrbutory factors affectng the behavour of the fre and to dentfy any Brgade practces or procedures whch may need to be revewed as a result. Those fndngs and any recommendatons arsng follow n ths secton. Any conclusons or recommendatons havng mplcatons outsde the Brgade enable the Chef Fre Offcer to consder whether he would wsh to commend those matters to the relevant authortes For ease of reference, the conclusons have been addressed n fve separate groups comprsng Personnel, Breathng Apparatus, Command and Control, Tranng, and Fre Safety Personnel Frefghter Fleur Lombard ded from shock and extensve burns beleved to have been caused by 'local deepenng' effects of a massve flashover producng an estmated heat output of 8 to 10MW at temperatures n excess of looo C whch were sustaned for a perod of up to three mnutes. Those condtons exceeded the desgn specfcatons of the personal protecton unform and breathng apparatus by up to four tmes thereby renderng the protecton provded neffectve. The operaton n whch Fleur was engaged wth her colleague, Frefghter 9 at the tme of her death was consdered to be a legtmate and justfable one. The command decson taken to commt the breathng apparatus wearers nto the buldng was based on sound and reasonable grounds consderng that the ntal fre appeared localsed n a dstant part of the supermarket and was beng controlled by jets n that locaton. The objectve of the decson was to penetrate a smoke-logged part of the shop to lay a gudelne and contan the fre from spreadng nto the unaffected area whlst searchng for mssng persons. The development of condtons symptomatc of a flashover would not normally be consdered lkely when a fre penetrates the roof as t had at Leo's when the frst crews arrved. The flames and rsng heat n such crcumstances would usually ndcate that the flammable gases present were beng drawn nto the fre, gnted and dscharged through the roof. As has now been proven wth such tragc consequences, these were not 'normal' condtons and the flash over that dd occur wth such devastatng effect could not have been foreseen when the breathng apparatus crews were frst commtted. When potental flash over condtons became apparent; (the rsng temperature and ncreasng nose), the evacuaton of crews had already been ntated and the approprate actons were taken. The tragc and unfortunate death offleur Lombard was the ultmate sacrfce of someone who was carryng out nstructons and dong her job to the best of her ablty. She was traned to the approprate standards to fulfl that role and even excelled n her competence. Both Fleur and Ff 9 were relatvely relaxed about the tasks that lay ahead when they frst entered the buldng and even exchanged banter between themselves as they progressed. Nether had been told anythng dfferent after they were approached by the Polce Constable before entry, who told them he was not su.re f everyone was out of the buldng. They were actng Wth the knowledge that customers mght stll have been n the supermarket whch always stmulates that addtonal motvaton and mpetus to stretch the lmts of personal endurance that only a professonal frefghter would know. Whlst becomng aware of the deteroratng condtons nsde when Ff 9 sad to Fleur that they would not be able to stay n much longer because of the heat; they were stll ~oth determned to complete ther task and te-off the gude lme at the end of the fateful asle before retreatng when, concdentally, t s thought that the evacuaton sgnal was receved by Fleur from the BAECO. n any normal crcumstances, both Fleur and Ff 9 would have wthdrawn from the buldng safely to 'notch up' yet another smokey breathng apparatus 'job'. nauspcously, these were not normal crcumstances but an nexplcable catastrophe whch consumed n ts wake, a very nnocent vctm. Both Fleur L.ombard and Ff 9 dsplayed gallantry equal to the fmest acts of bravery recorded and acted n the very hghest tradtons of the fre servce whose prmary functon s to save lfe. Ff 9 when he became aware of hs orentaton after the flashover, showed a concern for hs colleague whch was nstnctve and mmedate and whch prompted an nstant reacton to go to her ad wth absolutely no concern for hs personal safety. We RECOMMEND that the undaunted acts of valance dsplayed by Fleur Lombard and Ff 9 9 be consdered for a sutable award whch approprately recognses ther actons and whch could, n the case of Fleur Lombard, be awarded posthumously The courageous and gallant actons of Frefghter 7 n mmedately gong to the assstance of Page 56

63 Conclusons and Recommendatons Ff 9 n effectng the rescue of Fleur Lombard should also be recognsed n an approprate manner and We RECOMMEND that a sutable award that reflects such courageous and gallant actons should be consdered for Frefghter For dsplayng ntatve and forttude as the breathng apparatus emergency was unfoldng, by ntatng evacuaton, by assumng command of Entry Control Pont 2 when the emergency became apparent and by re-motvatng frefghtng operatons amongst devastated frefghters after recovery of the deceased, We RECOMMEND that Leadng Frefghter 1 be consdered for a sutable commendaton for hs actons n snglng out the above named ndvduals we recognse that the operatons were a team effort n whch several other personnel played a key role. We do not underestmate those efforts n extremely harrowng and dstressng crcumstances and we acknowledge the valorous actons of all personnel nvolved wth the ncdent, partcularly those drectly nvolved wth the breathng apparatus emergency We reported on our enqures concernng the general applcaton of breathng apparatus procedures n Paragraph n whch we recognsed and acknowledged that operatonal decsons are taken on the bass of calculated, professonal judgements made n the prevalng crcumstances at the tme. We also recorded how these cannot always be reconstructed after the event n a way whch shows the mperatves perceved by those nvolved. n the mnds of the Offcers nvolved at the tme, there wll always be doubt about the wsdom of ther actons and n partcular, the veracty of the decson to commt breathng apparatus wearers nto the buldng at all. We wsh to record that we have found no evdence whch has caused us to challenge or queston the command decsons taken to commt the breathng apparatus wearers although we have comments of a more general nature concernng brearhng apparatus procedures and command and control n the approprate sectons whch follow Through the course of our enqumes n conductng ths nvestgaton, t has been necessary to ntervew at length, the ndvduals n attendance at the ncdent at the crtcal tme. The ncdent had a profound effect on all members of the Brgade and many of those drectly nvolved, some of whom were also mmedate frends and colleagues of Fleur, were clearly sufferng the effects of the trauma n an extremely dstressng way. We pay trbute to the courage of those who asssted wth our enqures for ther forthrghtness, honesty and openness whch enabled us to reconstruct the events wth accuracy and confdence Breathng Apparatus Procedures Of the two teams of breathng apparatus wearers who entered the premses from Entry Control Pont 2, only Frefghter Lombard was equpped wth 'Sonc' rado communcatons equpment. Had Teams 1 and 2 been able to communcate wth each other they may not have become separated as they dd and therefore the hosereel beng carred by Team 2 would have been avalable for the protecton of all wearers whlst they were nsde. There s an nadequate provson of rado communcatons equpment for breathng apparatus. Each pumpng applance wthn the Brgade carres only one 'Sonc' equpped breathng apparatus set amongst the four breathng apparatus sets that are ssued to each applance. Due to a current shortage, two applances wthn the Brgade have no communcatons equpment for breathng apparatus ssued at the tme of preparng ths Report. As a breathng apparatus team normally conssts of two people t s consdered that ny.q communcaton sets should be provded for each pumpng applance. We RECOMMEND that the provson of at least one set of rado communcatons equpment for every breathng apparatus team be consdered a prorty for the Brgade n Paragraphs and we dscussed the term 'Breathng Apparatus Emergency' and hghlghted the confuson whch was apparent n the comprehenson of the termnology and the ambguty of the gudance avalable. No clear defntons appear to exst whch explan what precsely s meant by the terms 'breathng apparatus emergency' 'wearer n dstress', 'dstress to wearer; or' evacuaton procedure'. The fact that we elcted a range of very dfferent explanatons of those terms from qualfed breathng apparatus wearers and ndeed, from qualfed nstructors would seem to suggest that greater clarty s requred. Exactly what consttutes a 'breathng apparatus emergency' does not appear to be any more easly understood ether. The term appears n Techncal Bulletn 1/89 to descrbe a message whch should be ntated by a Stage Entry Control Offcer n the event of 'emergency' condtons arsng (Secton 23(1)()) as a code for Brgade Control to moblse renforcements. By way of comparson to those dutes, the duty of a Stage Entry Control Offcer n the event of 'emergency' condtons arsng s to "ntate emergency measures". t s assumed that the dfference between the two peces of gudance reflects the presence of an 'emergency' team under Stage Entry Control procedure whch may not be standng by under Stage where (n Avon Brgade) less than sx wearers are deployed. The term 'breathng apparatus emergency' s also common parlance to descrbe the condtons whch are declared n the event of a 'wearer n dstress' or' dstress to wearer'. n the absence of a clear defnton of these terms however, a 'breathng apparatus emergency' appears to be automatcally Page 57

64 Conclusons and Recommendatons declared followng the' dstressng' condton gvng rse to t. The addtonal actvtes whch should be trggered by a 'breathng apparatus emergency' declaraton are dfferent under Stage and Stage whch adds to the confuson and msunderstandng of the termnology. The actual use of the word 'emergency' throughout the gudance s ambguous n some contexts and appears to apply to all abnormal breathng apparatus condtons whether a 'real' emergency or not. Whlst recognsng that ths was probably ntentonal as a falsafe precauton when the gudance was prepared, an actual 'breathng apparatus emergency' procedure s not always justfed or necessary. n the absence of any dstncton between an 'urgent' and 'non-urgent' malfuncton or dstressng condton, the full blown emergency procedures apply n all cases whch may dlute the urgency and mportance whch should be assocated wth a lfe-threatenng emergency condton. The provson of addtonal breathng apparatus sets on fre applances n recent years has added greatly to the ablty to mplement emergency procedures n Stage for frst attendance applances whch has not been recognsed. The requrements for reportng 'notfable Dangerous Occurrences' under RDDOR whch amended Techncal Bulletn 1/89 n 1991 further confuses the perceved understandng of a 'breathng apparatus emergency' and a 'notfable Dangerous Occurrence'. Whlst those condtons may frequently conform to a smlar defnton, t does not apply n all cases. The gudance avalable n ths regard appears to be drven manly by the reportng requrements and the needs of a subsequent nvestgaton nto the cause of the malfuncton rather than the retreval and recovery of the dstressed breathng apparatus wearer. The mplcatons of the Management of Health and Safety at Work Regulatons 1992 may well nfluence a plan of acton for the recovery of a dstressed wearer as part of the rsk assessment process. n the lght of the apparent confuson about the termnology used n respect of breathng apparatus emergences, we RECOMMEND that the avalable gudance be revewed to consder what, f any, revsons may be approprate to rectfy the followng perceved defcences: (a) the absence of defnton or clarty of the terms "Breathng Apparatus Emergency", "wearer n dstress" and "dstress to wearer" (or any alternatves to those terms); (b) the absence of any precse actons whch should be followed or devsed n the event of those condtons arsng and n what crcumstances they are mplemented'; (c) the nconsstency of gudance under Stage and Stage breathng apparatus control n 'emergency' condtons; (d) a clear dstncton between measures necessary to retreve a stuaton or recover a dstressed wearer and the needs for reportng or subsequent nvestgaton, and; (e) the absence of any recognton of a dfference between "urgent" and "non-urgent" emergency condtons whch may requre dfferent levels of acton We dscussed n Paragraph and how the phenomenon known as 'local deepenng' would have evolved n the flashover condton that klled Fleur Lombard. We also summarsed, on the advce of the Fre Research Staton, that the deepenng layer of flame temperature gases at celng heght would curl down a vertcal obstructon towards floor level. t s the assumed behavour of those thermal flows that we beleve caused such devastatng njures to Fleur who was adjacent to the vertcal obstructon. Ff 9 who was slghtly further away, escaped the worst effects of the thermal flows but was thrown to the floor by the blast. f the hypothess s correct, there could be mplcatons on the advce gven to breathng apparatus wearers to mantan contact wth a sde wall when searchng n smoke. We RECOMMEND that the phenomenon 'local deepenng' be further nvestgated to determne any mplcatons for frefghters, partcularly when searchng or plottng a course n a smoke flled buldng We recommended n Paragraph above, the extended provson of rado communcatons equpment to ensure that a set s avalable for every team. Wth the excepton of a reference n a paper attached to 'Dear Chef Offcer letter 4/1988, no gudance has been found whch sets out a crtque n respect of breathng apparatus communcatons procedures. \Y./ e have already commented on the fact that the two teams of breathng apparatus wearers who entered through Entry Control Pont 2 may not have become separated had they both been equpped wth communcatons between them. We also beleve that ntellgence about the deteroratng condtons nsde the buldng pror to the fatal flashover could have been exchanged to better advantage both to and from the teams as nformaton became avalable. Whlst t would be speculaton to suggest that the avalablty of such ntellgence n the Leos ncdent could have led to an earler wthdrawal, the changng condtons would undoubtedly have been better known to all concerned n respect of very basc rsk assessment. We RECOMMEND that consderaton be gven to the development of a communcaton protocol between each team and ther breathng apparatus Control to montor progress of the team, condtons nsde, ntellgence about rsks and hazards, other frefghtng actvtes n progress and about nformaton whch the team nsde the rsk should know about. Page 58

65 Conclusons and Recommendatons We recognse n makng the above recommendaton, that such a procedure would place addtonal burdens on the exstng responsbltes of BAECO' s, partcularly n Stage breathng apparatus Control. The exstng dutes of the BAECO are already consdered onerous enough for what could be a very junor ndvdual especally f that responsblty should extend to ntatng emergency procedures or decdng on an evacuaton due to changng condtons. Any addtons to exstng responsbltes could well detract from the effectve dscharge of those dutes and as a result, undermne the prmary purpose of managng and controllng ther breathng apparatus Control Board. We RECOMMEND that an enhancement of exstng procedures should be consdered to provde for a dedcated Offcer-n-Charge of a breathng apparatus control pont, as and when resources permt, who should be a junor offcer rank and whose prncpal dutes would nclude: (a) mantanng rado communcaton wth teams workng from that entry pont; (b) loggng ntellgence gathered as a result of that communcaton and passng t on as approprate; ( c) takng responsblty from the BAECO for command decsons whch may arse; (d) mantanng a rsk assessment overvew to nform or ntate actons arsng out of nformaton receved. The approprate tme durng the progress of an ncdent at whch resources would permt ths escalaton may well concde wth the exstng gudance about the provson of an emergency team - e as and when resources permt or when the number of wearers at an entry pont exceeds ten (sx n Avon Fre Brgade) We reported that sgnfcant set backs to the nvestgaton process were the falure to recover and mpound the breathng apparatus set worn by Fleur Lombard, the delay n mpoundng the breathng apparatus control board causng t to be eventually mpounded n an ncomplete state, the dsposal by the hosptal authortes of Fleur Lombard's personal kt and the dverson to other dutes of the breathng apparatus emergency Supervsory Offcer. These were a catalogue of msfortunes whch have not been mpossble to overcome durng the nvestgaton but nonetheless should not have arsen f strct procedures had been followed. We RECOMMEND that a 'System of Work' be devsed whch sets out the exact procedures to be followed n addh:qd to and separate from any procedures arsng from the Recommendatons n Paragraph above n the event of a 'reportable Dangerous Occurrence'. The System of Work should nclude detaled nformaton about mpoundng equpment, preservng and photographng evdence, ndvdual responsbltes, supervson of the process, advce for ncdent commanders, the supervson of casualtes and the reportng requrements. The 'System of Work' should be readly avalable on the fre ground for the reference of the Supervsory Offcer We referred to dscrepances n the exstng advce gven n respect of the above n the Brgade's 0 & T Note A24 and the Applance and Equpment Manual, Secton B7. We RECOMMEND that the 0 & T Note on breathng apparatus procedures be revewed to address the dscrepances wth the A & E Manual, and at the same tme, to ensure that the 0 & T Note accurately reflects n suffcent detal, exactly what the Brgade's polces are where, ether they exceed those outlned n Techncal Bulletn 1189, or where the gudance contaned n the Techncal Bulletn requres elaboraton or talorng to sut the needs of Avon Fre Brgade. The Recommendatons n Paragraph above could be examples of the need for local clarfcaton should ths not be consdered approprate on a natonal bass Although we make no crtcsm of Fleur Lombard or Ff 9 n takng the actons they dd, we could not overlook the part experence played n ths tragc sequence of events and consder whether prevalng condtons could have nfluenced the outcome. Fleur Lombard had two years and three months servce and Ff 9 about four and a half years. At the tme we beleve Fleur receved the message to evacuate from the BAECO and conveyed that to Ff 9 by shoutng "Evacuate, evacuate", Ff 9 had already recognsed the worsenng condtons and told Fleur that "they wouldn't be able to stay n much longer". The decson to evacuate would probably have been taken by them anyway had the message not been receved. t s debateable whether a frefghter wth much longer servce than these two would have experenced or known how to recognse the symptoms of a serous deflagraton gven the speed of events n ths case. We cannot therefore conclude wth any convcton that greater expenence would have nfluenced the outcome. However, n the lght of our recommendaton for the development of a breathng apparatus communcatons protocol (Paragraph ) t would appear sensble to have the more experenced member of the team ftted wth the communcatons equpment. We RECOMMEND that consderaton be gven to revsng the gudance n ths respect to provde for the senor rank or most experenced member of the team to assume the role as 'team leader'. Page 59

66 Conclusons and Recommendatons 12.4 Command and Control We have hghlghted the confuson that arose when Teams 1 and 2 made ther ntal entry to the buldng from Entry Control Pont 2. Team 1 (Lombard/ 9 were unsure whether they were expected to take the hosereel as well as layng the gudelne. Frefghter 9 had to return to the BAECO to check that they had been detaled to lay the gudelne to the left. Frefghter Lombard when enterng, began to proceed to the rght before beng corrected by her colleague. Team 2 ( Ff 7 Ff 5 ) were not aware that the two teams should have been workng together or n what drecton they were supposed to proceed. Nether of the teams were aware that other breathng apparatus wearers were workng n another part of the shop and usng jets, and those breathng apparatus wearers were not told that further teams were enterng the buldng from a dfferent entry pont. The BAECO only became aware of the breathng apparatus teams' tasks by concdence and was not formally advsed of the command strategy or brefng gven. All of ths confuson could have been avoded through better brefng whch n ths nstance proved woefully nadequate. That the fatal outcome of the ncdent dd not appear to have been nfluenced by the poor brefng was fortutous and very lttle comfort can be derved from that. Brefng of breathng apparatus wearers pror to enterng the rsk area s a basc but essental command and control functon whch was not afforded a suffcently hgh level of prorty. A communcatons protocol and a dedcated Offcer-n-Charge of the entry control pont as recommended n Paragraphs and respectvely could well have overcome many of the brefng defcences for the breathng apparatus teams. We RECOMMEND that the mportance of good brefng and nformaton exchange n both drectons be gven a hgher profle n routne and refresher breathng apparatus tranng to ensure that breathng apparatus wearers n partcular are made aware of all relevant nformaton to provde them wth better control over ther own rsk management decsons and others nvolved n the control and management of breathng apparatus wearers are better acquanted wth freground events and command strategy Durng the frst ten mnutes nto the ncdent, the role of Offcer-n-Charge passed on no less than four tmes due to 'home ground' rules or senorty of rank. Ths was a clear mpedment to the development of a cohesve command and control strategy by ether offcer untl well nto the ncdent. The early stages of any fre ncdent are crucal and command decsons taken at that tme have a major mpact on evolvng condtons. A possble alternatve could be to contnue freground command under the responsblty of the senor offcer on arrval up to a pre-determned pont whlst more senor offcers attendng subsequently would assume the role of ncdent commander. We RECOMMEND that the queston of ncdent command n these crcumstances be reconsdered wth a vew to allowng a cohesve command and control strategy to be developed n the early stages of an ncdent n our endeavours to reconstruct the ncdent n Secton 5 of the Report, we became aware of the great dstances travelled by offcers around the freground ether n pursut of another offcer or to reconnotre progress n other parts. Overall control of the ncdent can be dmnshed by the need to be n so many dfferent places at the same tme and the assmlaton of nformaton suffers as a result. n the Leos ncdent, we reported how the Offcern-Charge frst became aware of the fatalty at the ncdent when he was asked by an ambulance paramedc f he wshed to vew the body. As a consequence of these factors, we are of the vew that the majorty of movements and ntellgence needs could be eradcated by effectve communcaton facltes. Currently, the provson of hand-held personal rados avalable on the freground s restrcted to two per pumpng applance wth fve on each of the Control Unt and the Chemcal ncdent Unt and two on each Rescue Tender. At an ncdent such as Leo's, where only pumpng applances would be n attendance n the early stages, the majorty of avalable rados would be held by the applance Offcers-n-Charge and ther contact pont - usually ther drver. Ths leaves an nadequate provson for other crew members or for senor offcers arrvng at the ncdent subsequently who therefore have to resort to makng personal contact wth ther subordnates or commandeerng a rado from an exstng holder whch depletes ther communcatons ablty. We RECOMMEND that consderaton be gven to the provson of addtonal personal rados as soon as possble to ncrease the number avalable on pumpng applances and to ensure that all offcers arrvng at an ncdent have personal access to one We reported on the fact that a polce constable n attendance at the Leo's ncdent had nformed Frefghters Lombard and 9 before entry that he was not sure f everyone n the supermarket had been accounted for. \Y/ e also reported that the polce constable had been drected towards the Staton Offcer-n-Charge and told to nform hm of hs concerns. The polce constable n the event, was unable to make mmedate contact wth the Staton Offcer due to hs preoccupaton wth freground command and t was not for several mnutes that the polce constable was able to express hs concerns to the Staton Offcer. Ether because the concerns were expressed dfferently to the Staton Offcer than they had been to Team 1, or because they were nterpreted dfferently by the Staton Offcer s not clear. Whatever the poston, the Staton Offcer appeared to understand that the polce constable's concerns appled n respect of the Labour Club rather than the supermarket. When the Staton Offcer conferred about ths wth the Sub Offcer, the Sub Offcer confrmed that Page 60

67 Conclusons and Recommendatons the Labour Club had been evacuated. Ths appears to be a clear example of msunderstandng whch causes concern. The polce constable's concerns that customers mght stll be n the supermarket as expressed to Fleur Lombard and Ff 9 were n fact, ll founded and based on hs conversaton wth the duty manager of the supermarket who had been unable to confrm that everyone was out. The polce constable, qute rghtly, consdered ths to be nformaton whch the Brgade ought to know about and he, qute rghtly, was drected to the Offcer-n-Charge. The fact that ths nformaton had not been countermanded, contradcted or retracted wth Team 1 was dscussed n Paragraph where approprate recommendatons were made. Our man concern arses n respect of a dfferent scenaro f the nformaton about persons nsde the buldng was accurate. The msunderstandngs n these crcumstances could have had much more serous mplcatons and therefore underlnes the mportance of ntellgence gatherng at any ncdent. We make no specfc recommendaton on ths ssue other than the need for greater emphass to be placed on brefng durng tranng whch has already been referred to but urge that relevant lessons be learned from these events whch also serve to renforce the need for mproved freground communcatons Tranng The standards of recrut tranng to whch all new entrants to the fre servce are subjected was found to be n conformty wth current gudance - Fre Servce Crcular 7/1974. The basc breathng apparatus tranng also conformed to the current standards lad down n Fre Servce Crcular 8/1981 and t has been noted that Fleur Lombard excelled n both areas and acheved the top marks on her recruts course to wn the coveted 'Slver Axe Award'. Our nvestgaton has not addressed the adequacy of the tranng n the present day envronment, as the ablty and competence of the breathng apparatus wearers n the performance of ther tasks has not been an ssue. We do however note that the recommended Wholetme Recrut Tranng Syllabus s 26 years old and the recommended breathng apparatus Tranng Syllabus s 15 years old. Whether those syllab stll reflect the tranng needs of todays frefghters and whether the latest knowledge and technology s adequately satsfed by the tranng are not questons that ths nvestgaton should have answered. We do however feel that the absence of real fre tranng n the breathng apparatus syllabus - e usng breathng apparatus n realstc condtons of heat and smoke rather than smulated condtons usng cosmetcally generated smoke, s an ssue whch may need to be reconsdered n the lght of ths ncdent. Although we do not cast any aspersons on the credblty of Fleur Lombard and Ff 9 experence of breathng' apparatus wearng n real fre condtons, exposure to such condtons n a tranng envronment has to have more postve than negatve effects on the completeness and preparedness of the ndvduals undergong that tranng. Ff 9 had the beneft of the Realstc Fre Tranng course undertaken at the Fre Servce College whlst Fleur Lombard dd not. To what extent that addtonal tranng experence may have affected the outcome at ths ncdent for Fleur Lombard s a matter of speculaton. Under the present tranng syllabus t would be theoretcally possble for a newly qualfed breathng apparatus wearer to emerge from tranng school, to be apponted to a watch as a traned member of a crew and attend as ther frst 'breathng apparatus job', another Leo's fre. t has been a source of some relef to report that newly qualfed frefghter recruts n Avon now attend the Realstc Fre Tranng course at the Fre Servce College durng the probatonary perod although fnancal resources prohbted ths durng Fleur Lombard's tranng. We beleve ths addtonal exposure to realstc condtons n a controlled tranng envronment to be an essental element of tranng whch should contnue. There are however, no facltes wthn the Brgade for real fre tranng whch prohbts any contnuaton tranng ether for routne or refresher tranng needs or for qualfed frefghters who have never had such tranng. There are also nadequate facltes wthn the Brgade for tranng n smulated heat and smoke whch places heavy demands on the one faclty that does exst and creates an neffcent and logstcal nghtmare to arrange annual breathng apparatus refresher courses for the whole Brgade at that one locaton. We RECOMMEND that prorty be gven to the provson of better facltes to mprove the standards of breathng apparatus tranng n both smulated and real fre condtons as a matter of urgency We referred to a number of nstances where prescrbed procedures were not strctly observed n several areas of breathng apparatus wearng and control procedures. Our recommendaton n Paragraph to rase the profle of good brefng durng tranng was one of those areas whch we felt requred specfc attenton for command and control reasons and to ensure that the breathng apparatus wearers themselves have the best qualty nformaton avalable to have greater control over ther own safety assessments and decsons. To be wholly effectve however, the wearers themselves have to fulfl ther oblgatons by observng the establshed procedures developed for ther own safety and that of ther colleagues. The lack of rgor towards breathng apparatus procedures that s occasonally wtnessed can be dffcult to comprehend to the unntated. f vewed n the context of the screamng mother approachng breathng apparatus wearers on arrval at an ncdent that her chld s trapped nsde the fre, any mtgaton of procedures becomes more understandable. The non-observance of safety procedures n such crcumstances s not through any blatant dsregard of the rules but usually because of the nstnctve urgency to do ther job, often n the face of nadequate resources to fulfl all of the needs at the tme. The pressures on those concerned at the Leo's ncdent has not been underestmated and we beleve that the oversghts n respect of breathng apparatus procedures were more unfortunate than delberate. We have no grounds to beleve that any procedural nadequaces affected the outcome of the ncdent or contrbuted n any way to_ the death of Fleur Page 61

68 Conclusons and Recommendatons Lombard. n attemptng to understand the crcumstances under whch the omssons arose, t would nonetheless be remss of ths Report not to draw attenton to these matters. We RECOMMEND that approprate steps are taken to: (a) reterate through tranng, the need to observe and practse the establshed polces and procedures on all occasons that breathng apparatus s worn; (b) to ensure at all tmes, that adequate resources are provded by the Brgade to facltate observance of the procedures We remarked n the Report on the dutes of the BAECO and we have made a recommendaton (Paragraph ) to enhance the exstng breathng apparatus procedures to provde for a dedcated Offcer-n-Charge of a breathng apparatus control pont. Offcers at all levels would normally only exercse a breathng apparatus controllng functon as part of ther command and control role farly nfrequently snce the BAECO would more often than not be a member of an applance crew rather than an offcer. The overall management of breathng apparatus control by offcers s a functon whch normally apples as breathng apparatus operatons escalate to Stage or Man. Control. The nfrequency of such ncdents provdes nsuffcent opportuntes for the management role to be practsed and the exstng lmtatons on resources make t extremely dffcult to nclude such tranng wthn the refresher programme. For a large scale breathng apparatus operaton to run effcently we beleve t to be vtally mportant that tranng scenaros should nclude the relevant level of offcerng at all scales of the ncdent to create the necessary realsm and to provde ongong refresher tranng opportuntes for the offcers themselves. We RECOMMEND that as soon as facltes and resources allow, tranng opportuntes be provded to allow offcers at the approprate levels to practse the management of breathng apparatus control on a regular bass n lne wth the realstc expectatons of ther potental role n the command and control of breathng apparatus operatons n Paragraph of the Report, we outlned n some detal the Probatonary Tranng Scheme to whch Fleur Lombard had been condtoned durng her probatonary perod. We reported on how the scheme had been devsed as a contnual assessment of objectve performance across a range of competences whch were weghted to gve balance and prorty to dfferent key result areas. Whlst not drectly assocated wth the ncdent at Leo's, we dd feel that t was encompassed wthn the Terms of Reference to note that revsons have subsequently been made to the Probatonary Tranng Scheme snce Fleur Lombard completed her recrut tranng that dmnsh the measurement of competence rather than enhance t. We feel that a comprehensve, competence based evaluaton of tranng receved s the most approprate method of valdatng competence levels of students partcularly n the feld of recrut and probatonary tranng. We RECOMMEND that the former concept of competence based valdaton of recrut and probatonary tranng be renstated as a matter of urgency We commented n Paragraph (Tranng n the Phenomenon of Flashovers) how the latest avalable nformaton on the subject had been publshed n 1995 as a supplement to Books 1 and 11 of the Manuals of Fremanshp. Although we were not able to establsh whether publcaton of the supplement nfluenced routne tranng programmes, we commented how no formal advce had been offered by the Brgade n respect of any actons whch need to be followed on recept of the new publcaton. Ths queston opened a more general lne of enqury whch extended to the way n whch new polces, procedures and specfc nformaton s communcated to operatonal personnel. We were of the opnon that n the general sense, nformaton s communcated farly effectvely through the medums of exstng Brgade promulgatons and ongong refnements of those procedures are streamlnng the process even further. We dd however, have reservatons about the way n whch the supplement had been ssued to statons wth no gudance about how ts contents mght nfluence tranng. Although the publcaton of supplements n that form s a new concept adopted by the Home Offce to keep brgades updated on new developments, the way the new nformaton s handled was equally mportant and we have been pleased to note that a new approach has been adopted by the Brgade as a drect result of ths fndng. We RECOMMEND that ncomng nformaton havng operatonal mplcatons becomes the subject of scrutny to assess any mpact on practces, polces or procedures about whch specfc advce should be offered and n partcular, about any tranng requrements arsng as a result n arrvng at the foregong conclusons n respect of tranng, we have hghlghted specfc aspects about whch we have made approprate recommendatons. nsofar as tranng generally s concerned, we are aware of the dffcultes the Brgade faces n fulfllng all nternal tranng needs whch nvolve takng personnel' off-the-run' to undergo the tranng due to rdershp factors. The Brgade's wholetme establshment provdes only suffcent personnel to meet mnmum crewng levels on applances. n the absence of an excess allowance for sckness, tranng or other unplanned absences, the ablty to remove people from operatonal dutes for tranng purposes s severely curtaled, partcularly when the establshment level falls Page 62

69 Conclusons and Recommendatons below the mlnlmum (as t frequently does n between recrut ntakes) or when an excessvely hgh number of personnel are absent on long-term sckness. Ths wll contnue to present a problem for the delvery of effectve, structured tranng to meet future ongong needs and to make sgnfcant mprovements to the exstng tranng provlslon. Many of the shortcomngs n procedure hghlghted n ths Report relate to breathng apparatus procedures whch have a tranng mplcaton. Whlst the Brgade's establshment remans at ts present levels, t s dffcult to envsage how major mprovements could be acheved to the absolute mnmum level of breathng apparatus refresher tranng provded at' the present wthout affectng the rders hp of operatonal fre applances. We RECOMMEND that further consderaton be gven to the Brgade's wholetme establshment level to examne ways of achevng a tranng allowance as soon as crcumstances permt Fre Safety We quoted n Paragraph the requrements ncumbent upon an occuper of a premse n respect of whch a Fre Certfcate was n force under Secton 29 of the OSRP Act. We also drew attenton to the followng matters whch arose as a consequence of our nvestgaton at Leo's. (a) The manual fre alarm system nstalled n the premses was not operated when the fre was dscovered. (b) The duty manager's spontaneous attempt to use the shop tannoy system to evacuate the store was foled (Paragraph 5.2.4). (c) There was no ordered or dscplned approach to the evacuaton of customers from the shop by staff after the fre was dscovered (Paragraph 5.2.3). (d) The contracted securty guard had not been famlarsed wth the buldng or the fre procedure when he reported for duty at the premses for the frst tme (Paragraph 5.1.2). (e) A member of staff was unable to tell the fre brgade the address of the premses durng the ntal 999 call (Paragraph 5.2.4). {Q The duty manager had to break out of the staff room wndow despte the fact that an ext door from that area showed a means of egress to open ar (Paragraph 5.3). Taken as a whole, these matters dd not engender hgh levels of confdence n the fre safety management culture prevalng at the store when the fre occurred. We were partcularly concerned to establsh whether the msnformaton about the possblty of customers remanng n the store whch was passed from the duty manager, to the polce constable and fnally to the fre offcer could have been avoded. The absence of a cohesve evacuaton procedure whch attempted to chaperone and clear customers out of the shop led us to conclude that there had not been an ordered evacuaton of the premses and the one checkout operator who dd attempt to check the asles for customers was actng on her own ntatve. Had an effectve evacuaton procedure been adopted to ensure that customers were drected towards exts and the asles were systematcally checked by staff, we feel t would be unlkely that customers would have been reported as beng unaccounted for nsde. n such crcumstances, Fleur Lombard and Ff 9 would not have heard the report about mssng persons and we feel may not therefore have stretched ther lmts of endurance as they dd. To ths extent we feel that the poor fre safety management procedures at the store could have nfluenced ther actons and those of the offcers n command of the ncdent The plan of the premses whch formed the Frst Schedule of the Fre Certfcate and whch remaned current at the tme of the fre showed that alteratons had been made to the premses snce the Certfcate was ssued whch dd not appear to have been the subject of consultaton wth the fre authorty as requred by Secton 30(2) of the Offces, Shops and Ralway Premses Act Alteratons appeared to have been made n the 'Butchery' (referred to n the Report as the 'Meat Preparaton Room') and n the area desgnated on the Certfcate as the 'Cafetera' (shown on the plans accompanyng ths Report as the Staff Room/Ktchen/Offces). Further alteratons affectng the 'Stock Room' and 'Bond' were also made as part of substantal alteratons to form a separate occupancy wthn the ground floor area whch was occuped by a furnture retaler at the tme of the fre. We have not been able to dentfy any consultaton records n respect of ether of those alteratons even though consultaton dd take place concernng a proposal to create offces at frst floor level n The man effect of the alteratons on the ground floor undertaken apparently wthout consultaton was to remove or alter the desgnaton of some of the fre ext doors detaled on the Schedule to the Fre Certfcate. We RECOMMEND that ths matter be made the subject of further nqures to establsh whether formal procedures were followed correctly and whether there was any breach of statutory requrements When drawngs were submtted by the CRS to the fre authorty n July 1972 showng proposed alteratons to the premses, a full schedule of recommendatons was ssued by the fre brgade n response on 1 August The recommendatons related only to proposed alteratons to the ground floor, the frst floor not beng proposed for use at that tme. Varous recommendatons were made n respect of means of escape, fre applances, fre alarm system and fre ext notlces together wth others under a 'General' headng. Page 63

70 Conclusons and Recommendatons Amongst them was: "n vew of the sze of the buldng thought should be gven to the nstallaton of an automatc sprnkler system, whch should be n strct complance wth the Fre Offces Commttee Rules for automatc sprnkler nstallatons together wth the approprate amend ments". The Schedule of Recommendatons also ntmated that the premses would become subject to the Offces, Shops and Ralway Premses Act 1963 when the proposed alteratons were completed. No powers exsted ether then or now, under whch the fre authorty could make the nstallaton of sprnklers compulsory n shop premses and the recommendaton could only therefore be on a goodwll bass. However, under certan crcumstances wth retal complexes requrng smoke control management measures, the provson of sprnklers would be an essental, mandatory element of the (means for securng) means of escape package, but generally speakng, under current Buldng Regulatons, sprnklers n shop premses are merely recommended n premses exceedng 7000m l (BS 5588: Part 2: 1985). The total capacty of the whole ground floor at Leos, by way of comparson was approxmately 4600m l. A sprnkler nstallaton may be desgned nto a speculatve buldng as a compensatory feature to satsfy a 'Functonal Requrement' under Buldng Regulatons when a dfferent requrement s not acheved. Sprnklers are unlkely to be nstalled n smaller buldngs smlar to Leos on a voluntary bass therefore, unless t became a requrement or the ncentves to do so were more persuasve. ncentves do currently exst through reduced nsurance premums and tax concessons on captal costs but these can to some extent be offset by the requrements of the water undertakng. The nsurance ndustry would appear to hold the key to ths dlemma and of course they frequently mpose stff requrements on occupers as a condton of nsurng the rsk. The growng tendency, partcularly for larger companes, to self-nsure part of ther rsk to a predetermned loss value before re-nsurng above set loss lmts, tends to undermne the nsurance ncentves for nstallng sprnklers. roncally, the commentary to the gudance on sprnkler systems contaned n BS 5588: Part 2, (Secton ) states: "The success rate of sprnkler systems n contanng fre outbreaks untl the arrval of the fre brgade has been put as hgh as 95% n cases where the system was n operatve order at the tme of the fre. There appears to be vrtually no weakness n these systems unless they are turned off for mantenance or buldng work, or through neglgence". The gudance avalable when the Certfcate was ssued to Leos n 1973 was very dfferent from the present, but the ncentves were n exstence at that tme. Whatever consderatons were taken nto account by the CRS at the tme, they dd not take up the recommendaton of the fre authorty to nstall sprnklers at the premses when the alteratons were proposed n We beleve that had an automatc sprnkler system been nstalled at the tme of the fre, early detecton would have been acheved n that unoccuped meat preparaton room where the fre started and the sprnklers would have controlled the spread and development of the fre before the fre brgade arrved and as a consequence, allowed the brgade a reasonable chance to contan and extngush the fre and save the buldng. Such a theory could have prevented the loss of lfe as a result. The enormous heat levels generated by the Leos fre were probably typcal of the output that could be expected from a totally nvolved retal occupancy of ths type. The estmated peak heat release of 8 to 10 Megawatts referred to n Paragraph , charactersed the hgh fre loadng whch exsted at the tme of the fre and provdes a sombre comparson to the 'standard' 5Mw 'desgn fre sze' used generally n calculatons for the desgn of smoke (and sprnkler) control measures. A hgh proporton of the commodtes stocked were of a combustble nature and the presence of 350 ltres of motor ol n plastc contaners together wth the added combustblty presented by LPG charged aerosol contaners and alcoholc sprts would certanly have ncreased the fre loadng sgnfcantly. Recent fres n other parts of the country n ths type of occupancy have made ther own contrbutons to the experences beng ganed about hgh loss fres n large sngle compartment retal outlets. Whlst clearly, these were dfferent crcumstances and whereas those more modern buldngs allowed for total loss of the stmcture (due to relaxed compartmentaton and fre resstance to elements of stmcture) but wth state of the art means of escape and evacuaton measures as compensaton. The older, more tradtonally constmcted stores wth smlar fre loadng have been subject to greater loss of lfe (\X7001worths, Lttlewoods etc) wth less damage to the stmcture. n the Leo's crcumstances we have the unfortunate combnaton of old desgn combned wth lack of compartmentaton and lack of fre resstance of elements of stmcture. Clearly n applyng modern rsk assessment technques to the older retal premses wth regard to lfe safety, some addtonal safety measures would be seen to be needed. We beleve there has never been greater justfcaton of the need for sprnklers n supermarkets than s avalable on present evdence and experence. The Leos fre leads us to conclude that the 7000m 3 benchmark recommended n BS 5588 for shops excludes a large number of small and medum occupances of ths type whch have a hgh fre loadng wth a potental for large numbers of people present. Many brgades have stepped back from even recommendng sprnklers - n the knowledge that they are unlkely to be even consdered for below 'cube' buldngs and have gone for more economc 'tradtonal' preventatve and detecton measures. Page 64

71 Conclusons and Recommendatons Retrospectve applcaton of regulatons has rarely been a feature of Brtsh law and on that bass, exstng occupances of a smlar type would escape any requrement to nstall sprnklers f new regulatons were ntroduced. For any sgnfcant mprovements to be made n ths stuaton, t appears to us that nducements to comply wth a recommendaton to nstall sprnklers must be far more attractve than at present. The queston of sprnkler provson n retal outlets has been a controversal ssue for some consderable tme and t s understandable that the economc argument should preval. The mbalance that appears to exst between property protecton and lfe protecton n the assessment of rsk by nsurers seems a dsncentve for the provson of passve fre protecton measures for lfe protecton. We RECOMMEND that the crtera and ncentves for the provson of automatc sprnkler nstallatons n medum and small retal outlets havng large undvded compartments be re-examned n the lght of the fre at Leos and the conclusons drawn from t We outlned n Paragraph the statutory oblgatons of the Brgade n respect of rsk famlarsaton under Secton l(l)(d) of the Fre Servces Act We also dentfed that whlst Leos would not qualfy for rsk nformaton or famlarsaton vsts the Brgade's exstng rsk nformaton system had not been mantaned for several years. We stated that the Rsk nformaton Card (Gen.3) had fallen nto dsrepute because of resource dffcultes n mantanng accurate up-to-date nformaton. A new 'Hazardous Premses' card system was devsed to obvate the dffcultes wth the former rsk nformaton card but was never launched. We also reported how the rsk famlarsaton vsts are ntated and managed by the watch Offcers-n-Charge. We feel that greater benefts could be derved from rsk famlarsaton, or 'l(l)(d)' vsts by clear gudance n a 'System of Work' whch defnes the purpose, ams, learnng outcomes etc together wth a defnton of the target rsk. t may be that ths s or should be a matter whch falls wthn the remt of the newly formed rsk assessment sub-commttee of the Safety Polcy Management Team. We RECOMMEND that a sutable system of rsk nformaton be resurrected or devsed that ncludes a 'System of Work' n respect of rsk famlarsaton vsts for operatonal crews and whch embodes tranng needs as well as rsk assessment needs The development of the Leos fre revealed a number of fre safety questons whch may requre further consderaton or research to establ sh whether current complance standards are adequate n the lght of the experences. We draw attenton to the ssues that arose n the course of the nvestgaton n the followng paragraphs whch are descrbed n more detal n the relevant parts of the Report. Whlst t was not consdered to be wthn the scope of the nvestgaton to delve too deeply nto the techncaltes of exstng and past gudance on these matters, we sngle them out for specal attenton because we beleve they were factors whch contrbuted to the rapd development of the fre and therefore to the condtons that caused the flashover. (a) We stated n Paragraph that we had no reason to beleve that the fbreboard celng panels nstalled at Leos dd not conform to the requred surface spread of flame standard at the tme of nstallaton. The FRS however, suggested that the exstence of the fbreboard celng wth the contnuous vod above t would probably have been one of the crucal factors havng a major contrbuton to the severty of the fre. The FRS also ndcated that they have experence of ageng fbreboard degradng over tme to Class 2 or 3 compared to the Class 1 that was orgnally specfed. f the observatons are correct, we would queston the long term sutablty of fbreboard as a false celng lnng n publc areas. (b) Whlst there would appear to have been no requrement for fre resstng separaton between the publc accessed retal area and the staff only warehouse area, ths was also suggested as one of the crucal factors contrbutng to the severty of the fre. n vew of the hgh fre loadng wthn the buldng, the absence of automatc fre detecton and the fact that the warehouse area was unoccuped, we feel that fre separaton n ths nstance would have had a major effect on contanng the fre. (c) As n (b) above, there appeared no requrement for vertcal fre separaton n the roof vod to prevent the spread of heat and smoke throughout the entre premse. n vew of the hybrd nature of the buldng and the consequent conglomeraton of roofng lnes and ptches we feel that the flow of hot gases n the roof vod could have been affected by the varous roof capactes whch could have been nfluenced by compartmentaton of the vod. The extenson of fre resstng separaton between the retal and warehouse area as referred to n (b) above to true roof heght would n tself we beleve have had a sgnfcant effect on spread. (d) The lack of fre separaton between the meat preparaton area and the retal area has already been commented upon. The formaton of the vod between the two areas when the delcatessen was replaced by a dsplay fxture s also consdered an mportant ssue because the vod was used for storage. The decson to use t for the storage of crsps and savoury products however, was unfortunate due to the hgh calorfc value of those commodtes whch was also a contrbutory factor n the development of the fre. We beleve that better gudance may be approprate n respect of the dsplay and storage of crsps and savoury snacks n partcular and ndeed, other commodtes of a hghly combustble nature unless passve protecton s provded. Page 65