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South Wales Fire & Rescue Service Gwasanaeth Tân ac Achub De Cymru Fire Brigades Union Fatal Accident Investigation Community Hall Newgale Place Ely Cardiff 23rd May 2004 Accident Investigation Report and Conclusions FOREWORD This report has been compiled by officers of South Wales Fire and Rescue Service and officials of the Fire Brigades Union in their capacity as Safety Representatives appointed under the Safety Committees Regulations 1977. The Accident Investigation Team was established on the morning of Sunday the 23rd May 2004. It was instructed to carry out an investigation in line with Brigade Order 14 Health and Safety, into the events surrounding the tragic death of Firefighter Richard Jenkins. The accident that led to his death occurred at Newgale Place Ely, Cardiff in the early hours of Sunday the 23rd May 2004. Both the brigade and union have co-operated fully with each other and there has been a free exchange of information. Each member of the Accident Investigation Team shares the findings and conclusions contained in this report. Mr GJ Clement Mr S Fleming Senior Divisional Officer Safety Representative South Wales Fire and Rescue Service Fire Brigades Union ~ SWFRS Mr K Barry Mr R Perry Divisional Officer Safety Representative South Wales Fire and Rescue Service Fire Brigades Union ~ Region 8 Page 2 of 37 Published September 2004 TABLE OF CONTENTS Section Subject Page 1 Accident Investigation Team…………………………………………... 5 2 Collation of Information……………………………………………….. 5 3 The Accident Site……………………………………………………… 6 4 Personnel Attending the Incident……………………………………… 8 5 Details of Injured Personnel…………………………………………… 9 6 Summary of Incident………………………………………………….. 10 7 Foreword to Narrative…….…………………………………………... 12 8 Incident Narrative……………………………………………………… 12 9 Narrative of Explosion………………………………………………… 25 10 Summary of Fire Investigation Report………………………………… 32 11 Conclusion and Recommendations……………………………………. 34 Figures Page 1 Plan of building………………………………………………………… 6 2 Plan of entrance lobby………………………………………………….. 6 3 Initial deployment of Ely crew…………………………………………. 15 4 Re-deployment of hose reel and location of main jet…………………... 16 5 Deployment of Ely’s crew immediately prior to arrival of Barry’s pump, 201………………………………………………………………. 17 6 Deployment of Ely and Barry crews at time when main entrance door is opened………………………………………………………………... 19 7 Deployment of crews at time of explosion……………………………... 21 8 Plan of entrance lobby post explosion………….………………………. 31 Page 3 of 37 Published September 2004 Photographs Page 01 Exterior view of building from the north west, showing the different roof levels……………………………………………………………… 7 02 Exterior view of south west corner, arrowed is area where fire was first attacked with hose reel………………………………………………... 14 03 Location, of open door on northern elevation………………………... 15 04 View through open door on northern elevation………………………. 15 05 Showing location of the first hydrant connected to Ely’s pump and the lamp post to which traffic tape was tied ( both arrowed)..……………. 20 06 Point A area where Firefighters 5 and 6 saw fire and point B area where SubO 1 saw fire………………………………….. 21 07 Showing damage to front of building caused by explosion……………. 26 08 Showing partial loss of tiles on southern pitch of lobby roof………….. 26 09 Showing total loss of tiles on northern pitch of lobby roof…………….. 26 10 Showing impact damage to front of helmet including, absence of visor, scrape to badge and timber on crown of helmet (arrowed)…………….. 27 11 LPG cylinder suspended from ceiling………………………….……… 28 12 Lobby area post explosion, LPG cylinder is top centre…...…………… 28 13 Top of cylinder showing holes (arrowed) test disc and valve………….. 29 14 Modern valve with pressure release valve (red)………………………... 29 15 Location of tripod and gas lamp (both arrowed)……………………….. 30 16 Scenes of Crime Officers excavating the main hall. The view is from the east with the wall and gable end removed. Double doors to entrance lobby are centre of picture……………………………………. 33 Appendices Page A Summary of significant timings………………………………………... 36 Page 4 of 37 Published September 2004 1 ACCIDENT INVESTIGATION TEAM 1.1 The Accident Investigation Team was established in accordance with Brigade Order 14, Health and Safety. It consisted of; Mr GJ Clement, Senior Divisional Officer, South Wales Fire and Rescue Service Mr S Fleming, Brigade Health and Safety Co-ordinator, Fire Brigades Union Mr K Barry, Temporary Senior Divisional Officer, South Wales Fire and Rescue Service Mr R Perry, Regional Health and Safety Co-ordinator, Fire Brigades Union Mr H & S 1 Health and Safety Officer, South Wales Fire and Rescue Service 1.2 The following personnel were co-opted onto the team to carryout specific tasks; Mr T/DO 1 Temporary Divisional Officer, South Wales Fire and Rescue Service Mr StnO 1 Station Officer, South Wales Fire and Rescue Service 2 COLLATION OF INFORMATION 2.1 The Accident Investigation Team commenced its investigation on the morning of the 23rd of May 2004. The initial phase involved an examination of the accident scene. Although this was restricted due to the structural instability of the building it was possible to analyse the area where Firefighter Jenkins was located at the time of the explosion, ie. the entrance lobby. 2.2 An in-depth study of this area was further hampered by the discovery of asbestos in part of the building and consequently the final excavation and examination of the entrance lobby was conducted by a fire investigation officer from South Wales Fire and Rescue Service and a member of the Forensic Science Service. 2.3 Due to a request from South Wales Police and a desire not to compromise the ongoing criminal investigation into the cause of the fire there was also a delay in interviewing the witnesses. However several of the crew members gave “hot” statements on the morning of the event prior to leaving the scene. In the days following the event all of the relevant witnesses were interviewed by the Accident Investigation Team and transcripts created. 2.4 As part of the investigation various electronic and paper records were examined. The most significant being the incident log, which was created by the Brigades Mobilising System and the other was the recordings of the 999 calls and radio messages. 2.5 Members of the team also attended various briefings held at Fairwater Police Station and during one of these information was provided by the Home Office Pathologist regarding the injuries to Firefighter Jenkins. 2.6 Technical guidance regarding liquid petroleum gas and gas cylinders was obtained during meetings and discussions with the British Oxygen Company, Calor and the LPG Gas Association. Page 5 of 37 Published September 2004 3 THE ACCIDENT SITE 3.1 The event occurred whilst attending a fire in a disused community centre in Newgale Place Ely, Cardiff. The detached building was approximately 22m by 10m and sat within a small curtalage with one area covered in tarmac and the other covered in grass. It was constructed mainly of timber with a pitched roof covered in cement based asbestos slate tiles. 3.2 The building was in two parts, the main portion comprising of a single storey assembly room. To the front were an entrance lobby, kitchen and two toilets. The entrance lobby provided access to the toilets, kitchen and assembly room. Above these rooms was a small storage area, access to which was gained via a hatchway in the main assembly room. Figure 1 ~ Plan of building ~ Not to Scale Toilets 4.5m Assembly Area 10m Lobby 4.5m Kitchen 10m 10.5m 22m Figure 2 ~ Plan of Entrance Lobby ~ Not to Scale Assembly Room 1.6m 2.6m 1m 1.5m Toilet 0.8m 3.8m 0.8m Kitchen 0.8m Toilet 1.2m 1m 1.1m Main Entrance Page 6 of 37 Published September 2004 Photograph 1 ~ Exterior view of building from the North West, showing the different roof levels. Page 7 of 37 Published September 2004 4 PERSONNEL ATTENDING THE INCIDENT 4.1 The following is a list of a) Appliances that attended the incident, excluding relief or ancillary crews and b) Officers that attended in a command capacity, it does not include brigade personnel that attended for investigation or welfare purposes. Appliances Initial Attendance Ely ~ 521 Sub Officer 1 Officer in Charge Firefighter 1 Driver Firefighter 2 Firefighter 3 Initial Attendance Barry ~ 201 Acting Station Officer 1 Officer in Charge Firefighter 4 Driver Firefighter R Jenkins Firefighter 5 Firefighter 6 Make Pumps 3 Penarth ~ 221 Sub Officer 2 Officer in Charge Firefighter 7 Driver Leading Firefighter 1 Firefighter 8 Firefighter 9 Make Pumps 4 Central ~ 512 Leading Firefighter 2 Officer in Charge Firefighter 10 Driver Firefighter 11 Firefighter 12 Officers S11 Temporary Assistant Divisional Officer 1 A13 Temporary Divisional Officer 1 Page 8 of 37 Published September 2004 5 DETAILS OF INJURED PERSONNEL 5.1 A total of three brigade personnel received injuries as a direct result of the explosion Richard Jenkins Firefighter Date of Birth: Age: 28 Date Joined Service: 27th February 1995 (initially joined London Fire Brigade, transferred to South Wales on 7th January 2002) Post and work location: Station 20 Barry. Injuries: Fatal head injuries SubO 1 Sub Officer Date of Birth: Age: 48 Date Joined Service: 4th December 1981 Post and work location: Station 52, Ely. Injuries: Flash burns to face. A/StnO 1 Sub Officer xxxxxx Age: 38 Date Joined Service: 7th January 1985 Post and work location: Station 20 Barry. Injuries: Flash burns to face. Page 9 of 37 Published September 2004 6 SUMMARY OF INCIDENT 6.1 At 01:07:37 hrs on the morning of Sunday the 23rd May 2004 the brigade received a report of fire in the “green hut” in Newgale Place Ely, Cardiff. Two pumping appliances were responded to the incident, one from Ely station, commanded by Sub Officer (SubO) 1 and the other from Barry, commanded by Acting Station Officer (A/StnO) 1 6.2 The first pump to arrive was Ely and as they approached the scene the officer in charge could see what he thought was either smoke or low level clouds in the direction of Newgale Place.

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