The Marlie Farm Explosion

Transcription

1 The Marlie Farm Explosion Significant Findings of the Investigation into the Fire and Fatal Explosion Festival Fireworks Ltd, Marlie Farm, Ringmer, East Sussex, U.K. Sunday 3 December 2006 Photo of accident site on the following morning

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3 CONTENTS Recommendations of the Accident Investigation Team... 1 Introduction Scope of the Report The Site Explosive (Fireworks) Legislation in the United Kingdom UN ADR Hazard Division (UN HD) Definitions Classification of Explosives for Transport Classification of Fireworks Default Classification Scheme LOCEF CHAF Hazard Type Importation Controls Licensing at the Marlie Farm Site Events leading up to the Incident Initial Stages of Incident Prior to the Fire and Rescue Service Involvement Summary of Incident The Explosion Size of Explosion Possible Content of the ISO Container Criminal Charges Use of ISO Containers Summary of Actions by East Sussex Fire & Rescue Service Post Explosion How the Accident Investigation was Carried Out Phase 1 of the Investigation Phase 2 of the Investigation Phase 3 of the Investigation How the Fire Investigation was Undertaken Findings of the Fire Investigation STEP Incident Timeline Findings and Recommendations of the Accident Investigation Team Premises Location of Fireworks Post Explosion Contingency Plan / 7(2)(D) Process The Control of Major Accident Hazards Regulations 1999, as amended Open Water Supplies Register not Completed i

4 Plant, Equipment and Substances MODAS Support from Other Fire and Rescue Services Personal Protective Equipment (PPE) PPE Afforded Some Protection against Blast, Sound and Projectiles Helmets Other PPE Misunderstanding Capability of PPE Fire Boots Fire Helmets Firefighting Clothing and Gloves Consideration of PPE Requirements Within the Dynamic Risk Assessment Process Use of Fire Hoods Eye and Facial Protection Hearing Protection PPE Item Not Worn by Correct Wearer Routine PPE Checks Audits by Firefighting PPE Contractor Maintenance Records for Firefighting PPE Items Use of PPE by Media Co-ordinator When Attending Incidents Performance of Operational Equipment Correct Equipment not Available, i.e. Improvised Monitors Being Used Communications Equipment Use of Fireground Radios Types of Fireground Radios Audibility of Fireground Communications Use of Mobile Telephones for Formal Messages from the Fireground Main Scheme Radios in Officers Cars Use of Radios and Other Communication Devices in Proximity to Explosives Communication Difficulties Process for the Provision and Use of New Operational Work Equipment Procedures Speed and Weight of Response in Accordance with IRMP Proactive/Early Make-ups Incident Command System Appropriate Command Teams Established at Level 1, Level 2 and Level Span of Control and Lines of Communication Excessive ii

5 Evacuation Procedures and Roll Call Communication of Tactical Plan Driven by Events Joint Agency Control of Members of Public, Personnel and Cordon Procedures Acetylene Risk and Service Procedure Crewing of the Incident Command Unit Recall to Duty Procedure People Actions by M&CC Throughout the Incident Support Staff Attending Incidents Role of Duty Officer Mobile Data Terminals Welfare Arrangements Family Liaison Assessing Risk Implementation of Controls for Support Staff Attending Incidents and Entering Risk Areas Risk Assessment Process Allocation and Internal Vetting Review of Risk Assessment Following Safety Event Organisation: Control Tradition and Experience of Fireworks in East Sussex: Failure to Recognise Fireworks as Hazardous Substances - HSG Post Incident Record of Attendance Organisation: Co-operation Organisation: Communication Process for Sharing Intelligence Regarding Incidents Involving Bulk Storage of Fireworks Interface Between Fire & Rescue Service and Other Enforcement Agencies Pre-Incident Liaison Between Emergency Services Effectiveness of Process for Communicating Findings of Risk Assessments Equipment Risk Assessment for Firefighting PPE Organisation: Competence Training Incident Command Station-Based Training Activity for Firefighters, Crew and Watch Commanders Course-based Training for Personnel Health and Safety Risk Assessor Training for New Firefighters Syllabus for Trainee Firefighter Programmes Competence Following Induction iii

6 Assessment and Development Centres (ADC) Continuous Development Training for Specialist Officers, e.g. Water Officer Training Needs Identified by Risk Assessment Shortfalls in the Achievement of Targets for Station-Based Continuation Training Portable Pump Operator Training Training Packages/Presentations to Support Continuation Training at Station Level Operational Activities not Covered by ACTIVAT Recording of Operational Activity as Training Exceptions in Records of Training for Specialist Appliances and Operational Equipment Exceptions in Records of Significant Employment Milestones Shortfalls in Records for Course-Based Training Training of Hazardous Materials Environmental Protection Officers (HMEPOs) Evidence of Training Exercises at Risk Premises Monitoring of the Exercise Schedule Venues for Exercises Recording of Training at Exercises Availability of Defined Learning and Development Requirements for Each Role Issues Regarding Explosives Arising During the Legal Process Procedures for Dealing with Explosives Incidents Central Guidance to UK Fire Services East Sussex Fire & Rescue Service Risk Assessment for Explosives Incidents Previous Incidents Involving Fireworks The Manufacture and Storage of Explosives Regulations Liaison with Occupiers Training Continuation Training Explosives External Courses - Wholetime External Courses - Retained Other Explosives Training Appendix A Charges Regarding Incident Appendix B Glossary of Abbreviations.240 Appendix C Fire Officers' Association Comments..242 Appendix D Letter from Health and Safety Executive iv