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
CONTENTS Recommendations of the Accident Investigation Team... 1 Introduction... 18 Scope of the Report... 18 The Site... 19 Explosive (Fireworks) Legislation in the United Kingdom... 23 UN ADR Hazard Division (UN HD) Definitions... 24 Classification of Explosives for Transport... 24 Classification of Fireworks... 25 Default Classification Scheme... 27 LOCEF... 28 CHAF... 29 Hazard Type... 29 Importation Controls... 30 Licensing at the Marlie Farm Site... 30 Events leading up to the Incident... 33 Initial Stages of Incident Prior to the Fire and Rescue Service Involvement... 33 Summary of Incident... 36 The Explosion... 43 Size of Explosion... 48 Possible Content of the ISO Container... 49 Criminal Charges... 50 Use of ISO Containers... 50 Summary of Actions by East Sussex Fire & Rescue Service Post Explosion... 51 How the Accident Investigation was Carried Out... 52 Phase 1 of the Investigation... 53 Phase 2 of the Investigation... 55 Phase 3 of the Investigation... 55 How the Fire Investigation was Undertaken... 56 Findings of the Fire Investigation... 56 STEP Incident Timeline... 57 Findings and Recommendations of the Accident Investigation Team... 131 Premises... 132 Location of Fireworks Post Explosion... 132 Contingency Plan / 7(2)(D) Process... 140 The Control of Major Accident Hazards Regulations 1999, as amended 2005.... 142 Open Water Supplies Register not Completed... 143 i
Plant, Equipment and Substances... 144 MODAS... 144 Support from Other Fire and Rescue Services... 145 Personal Protective Equipment (PPE)... 146 PPE Afforded Some Protection against Blast, Sound and Projectiles... 146 Helmets... 146 Other PPE... 147 Misunderstanding Capability of PPE... 150 Fire Boots... 150 Fire Helmets... 150 Firefighting Clothing and Gloves... 151 Consideration of PPE Requirements Within the Dynamic Risk Assessment Process... 151 Use of Fire Hoods... 152 Eye and Facial Protection... 153 Hearing Protection... 153 PPE Item Not Worn by Correct Wearer... 155 Routine PPE Checks... 155 Audits by Firefighting PPE Contractor... 155 Maintenance Records for Firefighting PPE Items... 156 Use of PPE by Media Co-ordinator When Attending Incidents... 156 Performance of Operational Equipment... 157 Correct Equipment not Available, i.e. Improvised Monitors Being Used... 159 Communications Equipment... 160 Use of Fireground Radios... 160 Types of Fireground Radios... 160 Audibility of Fireground Communications... 163 Use of Mobile Telephones for Formal Messages from the Fireground... 164 Main Scheme Radios in Officers Cars... 164 Use of Radios and Other Communication Devices in Proximity to Explosives... 164 Communication Difficulties... 165 Process for the Provision and Use of New Operational Work Equipment... 165 Procedures... 165 Speed and Weight of Response in Accordance with IRMP... 165 Proactive/Early Make-ups... 166 Incident Command System... 167 Appropriate Command Teams Established at Level 1, Level 2 and Level 3... 168 Span of Control and Lines of Communication Excessive... 171 ii
Evacuation Procedures and Roll Call... 173 Communication of Tactical Plan Driven by Events... 176 Joint Agency Control of Members of Public, Personnel and Cordon Procedures... 177 Acetylene Risk and Service Procedure... 178 Crewing of the Incident Command Unit... 180 Recall to Duty Procedure... 182 People... 182 Actions by M&CC Throughout the Incident... 182 Support Staff Attending Incidents... 183 Role of Duty Officer... 184 Mobile Data Terminals... 185 Welfare Arrangements... 185 Family Liaison... 186 Assessing Risk... 186 Implementation of Controls for Support Staff Attending Incidents and Entering Risk Areas... 186 Risk Assessment Process Allocation and Internal Vetting... 190 Review of Risk Assessment Following Safety Event... 192 Organisation: Control... 193 Tradition and Experience of Fireworks in East Sussex:... 193 Failure to Recognise Fireworks as Hazardous Substances - HSG 48... 193 Post Incident Record of Attendance... 195 Organisation: Co-operation... 195 Organisation: Communication... 195 Process for Sharing Intelligence Regarding Incidents Involving Bulk Storage of Fireworks... 195 Interface Between Fire & Rescue Service and Other Enforcement Agencies Pre-Incident... 197 Liaison Between Emergency Services... 199 Effectiveness of Process for Communicating Findings of Risk Assessments... 200 Equipment Risk Assessment for Firefighting PPE... 201 Organisation: Competence... 201 Training... 201 Incident Command... 201 Station-Based Training Activity for Firefighters, Crew and Watch Commanders... 202 Course-based Training for Personnel... 206 Health and Safety Risk Assessor... 207 Training for New Firefighters... 207 Syllabus for Trainee Firefighter Programmes... 208 Competence Following Induction... 208 iii
Assessment and Development Centres (ADC)... 209 Continuous Development... 209 Training for Specialist Officers, e.g. Water Officer... 210 Training Needs Identified by Risk Assessment... 211 Shortfalls in the Achievement of Targets for Station-Based Continuation Training... 212 Portable Pump Operator Training... 213 Training Packages/Presentations to Support Continuation Training at Station Level... 214 Operational Activities not Covered by ACTIVAT... 215 Recording of Operational Activity as Training... 217 Exceptions in Records of Training for Specialist Appliances and Operational Equipment... 218 Exceptions in Records of Significant Employment Milestones... 219 Shortfalls in Records for Course-Based Training... 220 Training of Hazardous Materials Environmental Protection Officers (HMEPOs)... 221 Evidence of Training Exercises at Risk Premises... 221 Monitoring of the Exercise Schedule... 222 Venues for Exercises - 2006... 222 Recording of Training at Exercises... 223 Availability of Defined Learning and Development Requirements for Each Role... 223 Issues Regarding Explosives Arising During the Legal Process... 225 Procedures for Dealing with Explosives Incidents... 225 Central Guidance to UK Fire Services... 225 East Sussex Fire & Rescue Service Risk Assessment for Explosives Incidents... 226 Previous Incidents Involving Fireworks... 226 The Manufacture and Storage of Explosives Regulations 2005... 226 Liaison with Occupiers... 228 Training... 230 Continuation Training Explosives... 230 External Courses - Wholetime... 231 External Courses - Retained... 232 Other Explosives Training... 233 Appendix A Charges Regarding Incident... 238 Appendix B Glossary of Abbreviations.240 Appendix C Fire Officers' Association Comments..242 Appendix D Letter from Health and Safety Executive... 244 iv