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. As they turned into Newgale Place the crew saw light coloured smoke issuing from the eaves of a single storey community hall. They booked in attendance at 01:13:27 hrs.
6.3 SubO 1 commenced a risk assessment and noted smoke drifting north and flames breaking though the cladding on the south side of the building. Initially he believed the building was secure but he located an open door on the north side of the building. Through this door he could see a layer of smoke below which there were flames.
6.4 The crew in the back of Ely’s pump, Ff’s 2 and 3 initially got a hose reel to work on the south side of building but following instructions from SubO 1 they repositioned to the open door on the north side.
6.5 SubO 1 formed the opinion that to effectively attack the fire they would need to apply water through another door and that they would also need to get a jet to work. He consequently sent an assistance message making pumps three at 01:15:10 hrs. The driver, Ff 1 had already anticipated the need for a main jet and had run one out. Ff 3 following discussions with the SubO had got a sledgehammer ready to force the main entrance door but he was instructed to wait until the main jet had water, as a result he assisted Ff 1 to set into a nearby hydrant.
6.6 At 01:18:57 Barry’s pump arrived at the scene. A/StnO 1 met with SubO 1 and discussed issues such as the type of fire they were confronted with and water. He made an assessment of the situation and concluded they were dealing with a “well ventilated respectable size fire”. They both formed the opinion that they would need to force the main entrance door to enable them to get adequate water onto the fire.
6.7 A/StnO 1 felt that the incident was under control and that there was no need for him to take command. He was wearing his normal rank markings of a SubO and therefore SubO 1 had no reason to believe that he was an A/StnO and consequently (in line with accepted protocols) assumed he was in charge of the incident.
6.8 SubO 1 gave instructions to get a main jet to work on the northern side of the building. This was done by Ff’s 5 and 6 crew members of Barry’s pump. A/StnO instructed Ff 4 the driver of Barry’s pump, to get a hose reel off the appliance and as he started to pay out the hose Ff Jenkins (the fifth member of Barry’s pump) took the branch from him and approached the front of the building.
6.9 A/StnO 1 assisted by Ff 4 started to force the main entrance door with a sledgehammer. As they were doing so SubO 1 and Ff Jenkins were standing nearby, at the point when the door was finally opened they were joined by Ff 3
Page 10 of 37 Published September 2004 They described the conditions in the entrance lobby as being clear of smoke and with the exception of flames starting to penetrate from the assembly area around the upper half of the double doors, the lobby area was clear of fire.
6.10 Ff Jenkins approached the doorway and was instructed by A/StnO 1 to play some water onto the lobby ceiling. This was to check its stability and ensure nothing was likely to come down on them.
6.11 At this point in time Ff’s 2 5 and 6 who were working on the northern side of the building noticed that the fire involving the main roof had become more significant. In addition Ff 5 recalled seeing fire breaking out in the middle of the roof over the entrance lobby. SubO 1 who had moved away from the entrance door to view activities on the northern side of the building also noted that fire had started to breakout through the gable end of the main roof over the assembly area and he shouted to one of the firefighters to direct water onto that area. When he returned to the front of the building Ff Jenkins had entered the entrance lobby and A/StnO 1 was on the threshold.
6.12 At this moment there was an explosion which engulfed both A/StnO 1 and SubO 1 When the crew members regained their composure, A/StnO 1 and Ff’s 2 and 3 entered the building to rescue Ff Jenkins who was still inside the building. As they entered they saw his body lying facedown and motionless on the floor. They carried him to outside and placed him on the pavement. They were then joined by other crew members and attempts were made to resuscitate him.
6.13 Assistance messages were sent requesting an ambulance and an additional pump. The ambulance arrived at the scene at approximately 01:30 hrs and the paramedics took control of resuscitation. Ff Jenkins was transferred to the Accident and Emergency Unit at the University Hospital of Wales and at 01.55hrs he was pronounced dead.
6.14 The stop message for the incident was sent at 03:36 hrs.
Page 11 of 37 Published September 2004 7 FOREWORD TO NARRATIVE
7.1 Occasionally the times quoted in the following narrative differ from those recorded on the Incident Log created by Brigade Control. The times in this narrative are taken from the audio recordings and are the time when each communication commences. That is the point when the person initiating the communication relays their respective call sign. In contrast the times recorded on the Incident Log are created when the operator presses the return key after entering the text.
7.2 The times relating to the movements of the ambulance have been obtained from Ambulance Control. They have been adjusted to reflect the time differential between the clocks in the respective control rooms. The investigation was not able to determine the exact difference in the timings but it is known that on the night of the incident the clock in Ambulance Control was running a minimum of 32 seconds behind the one in Brigade Control.
7.3 A summary of the significant times is contained in appendix A.
8 INCIDENT NARRATIVE
8.1 At 01:07 hrs and 37 seconds on Sunday the 23rd May 2004 British Telecom connected the first of twenty two 999 calls to Brigade Control. At 01:07 and 41 seconds the Control Room Operator that answered the call created a new incident, number 09375.
Control Hello fire service. BT Operator Connecting 02920317253 Control Thank you, fire service can I help Caller There’s a fire across the road from us at, 3 Newgale Place the green hut is. Control What’s on fire there? Caller I’m not sure I think the whole building is. Control What sort of building is it? Caller Um the green hut it is next by the council office. Control Near the council office Caller Yea. Control Is it actually part of the council office? Caller Um no it’s the actual green hut it’s across it’s the top of Bishopston road. Control Right you said it was opposite Newgale place is it. Caller Yea opposite Newgale place Control And where is Newgale place?
Page 12 of 37 Published September 2004 Caller Um just off the Heol Pant Y Deri. Control Which town then? Caller It’s in Ely like Caerau. Control Is it Caerau? Caller Yea. Control And it’s off Bishopston town place Caller Bishopston road. Control Bishopston, road you said was it? Caller Yea. Control Ok no problem we are on our way there. Caller Alright then thank you. Control Ok. Caller Tara. Control Bye.
8.2 The Control Room Operator entered the call details into the mobilising system. Although the initial caller stated that the fire was in “the green hut” she mistakenly typed in “green house”. However this error did not have any adverse effect on the level of response to the incident. The mobilising system produced a pre-determined attendance of two pumping appliances and one Station Officer (StnO).
8.3 The two pumping appliances that would have normally attended would be 521 from Ely and Barry’s second pump 202. In addition a flexible duty StnO would have responded from their residence.
8.4 At the same time that this call was being processed the brigade was also in attendance at another incident involving a person who had fallen down some rocks near Ogmore By Sea. This resulted in 202 being taken off the run in order for its crew to take a specialist rescue unit to that incident.
8.5 Consequently Barry’s first pump 201 responded to the report of fire in Newgale Place. A StnO commands this appliance and therefore there was no requirement to mobilise a flexible duty StnO to the incident.
8.6 521 booked mobile to the incident at 01:10 hrs and 30 seconds. The officer in charge, Sub Officer (SubO) 1 relayed the information on the turnout slip to his crew, ie. “fire in a green house”. On leaving the station the appliance turned left onto Cowbridge Road West, from there into Amroth Road and Bishopston Road and finally into Newgale Place. As they approached the roundabout at the end of Bishopston Road SubO 1 and Firefighter (Ff) 1 the driver, noticed what they believe to be either smoke or low clouds in the direction of Newgale Place. They also spotted a gentleman waving a large flash lamp, they assumed he was trying to attract their attention and guide them to the fire.
Page 13 of 37 Published September 2004 8.7 The appliance proceeded straight on at the roundabout and as it travelled around the bend into Newgale Place the building involved in fire came into view. At this stage there was light coloured smoke issuing from the eaves of the roof that covered the main assembly area. The appliance booked in attendance at 01:13 hrs and 27 seconds and was parked just past the main entrance to the building.
8.8 SubO 1 alighted from the appliance and commenced a risk assessment of the incident. He had immediate access to approximately one quarter of the south elevation and the entire west and north elevations. Security fencing and gates restricted access to the remainder. He saw smoke drifting north and flames on the south side breaking through the timber cladding at the point where the two roofs intersected. Initially he thought that the building was secure and that he would have to force entry to get water onto the fire. However reacting to information given to him by Ff 1 he located an open door approximately half way along the north elevation (see photograph 3). As he approached he saw smoke issuing from the doorway and when he looked through the door into the main assembly area he could see some flames below the smoke layer.
8.9 Ff’s 2 and 3 who were sat in the back of the appliance, offside and nearside respectively, dismounted and got a hose reel jet to work on the south elevation of the building where the flames had broken out.
Photograph 2 ~ Exterior view of south west corner, arrowed is area where fire was first attacked with hose reel.
Page 14 of 37 Published September 2004 Not to Scale ● ● 521 Ff 2 & Ff 3 N H Toilets Ff 1
Assembly Area Lobby
Kitchen SubO 1
LP
Figure 3 ~ Initial deployment of crew.
8.10 After a short time they felt they were having little impact on the fire and being aware of the open door on the northern side of the building decided to move to that area. As they were relocating they met SubO 1 who instructed Ff 2 to take the hose reel jet to the doorway in question where they would be able to get some water onto the fire.
Above - Photograph 3 ~ Location of open door on northern elevation.
Right – Photograph 4 ~ View through open door on northern elevation.
Page 15 of 37 Published September 2004 8.11 As part of his assessment SubO 1 concluded that he would need additional resources to deal with the incident and at 01:15hrs and 30 seconds (two minutes and three seconds after arrival) he sent an assistance message to Brigade Control requesting an additional pumping appliance.
SubO 1 SB from 521 over. Control Go ahead over. SubO 1 SB 521, from Sub Officer 1 at Newgale Place Caerau, fire involving large detached building, make pumps three, 521 over. Control Confirm make pumps three over. SubO 1 Answer yes, 521 over. Control Received, 201 over. A/StnO 1 Message received SB, 201 over. Control Received SB out
8.12 Brigade Control complied with the request and responded the additional appliance from Penarth, 221. That appliance booked mobile to the incident at 01:17hrs and 38 seconds.
8.13 After sending the message SubO 1 briefly returned to the location of Ff’s 2 and 3 and instructed Ff 2 not to enter the building but to remain outside. He then concluded that a main jet would be needed to tackle the fire. Ff 1 had already pre-empted this decision and had started to run out a main jet consisting of two lengths of hose. He placed it near the front of building with the hose flaked.
Not to Scale ● ● 521 N H Toilets Ff 1
Assembly Area Lobby
Kitchen SubO 1
Ff 2 & Ff 3
LP
Figure 4 ~ Re-deployment of hose reel and location of main jet.
Page 16 of 37 Published September 2004 8.14 Ff 3 then returned to the front of the building where he discussed with SubO 1 the option of gaining entry via the main entrance. In readiness Ff 3 removed the sledgehammer and hooligan tool from the appliance and took them to the main entrance, however the SubO instructed him to wait until the main jet was ready. So instead he proceeded to assist Ff 1 who had started to run out hose from a nearby hydrant.
8.15 At the time when Ff’s 1 and 3 were setting into the hydrant SubO 1 believes he took the flaked main jet down the north side of the building to the same location as Ff 2 and directed water onto the roof. However Ff 2 does not recall seeing him do this and furthermore when Ff’s 5 and 6 from Barry got the same jet to work later on they claim the hose had not been previously charged (paragraph 8.21).
Not to Scale ● ● 521 N H Ff 3 Toilets Ff 1
Assembly Area Lobby
Kitchen
SubO 1
Ff 2 LP
Figure 5 ~ Deployment of Ely’s crew immediately prior to arrival of Barry’s pump, 201.
8.16 At 01:18 hrs and 57 seconds Barry’s pump 201 arrived at the scene. A StnO always commands 201 but on the night of the fire the substantive officer was not on duty. Consequently and in accordance with brigade procedures SubO 2 acted up to the rank of StnO for the night. An “Acting” rank is held by a person who normally holds a substantive rank beneath that at which they are acting. Ranks then act up to the next tier to make up for short term managerial deficiencies. An acting position can be held for as little as one shift.
8.17 Initially the Barry crew were also under the impression that they were responding to a fire involving a green house. However whilst still on route to the incident, Brigade Control relayed SubO 1's assistance message This informed them that the fire was involving a “large detached building”.
Page 17 of 37 Published September 2004 8.18 As they arrived smoke was issuing from the northern eaves of the entrance lobby roof and fire had started to break through the main roof. Acting StnO (A/StnO) 1 dismounted from the appliance and met with SubO 1 who had made his way to the front of the building. They had a conversation which was succinct and revolved around general issues such as the sort of fire they were confronted with and water supplies.
8.19 A/StnO 1's assessment of the situation was that the incident was under control and water supplies were being dealt with. He made a quick overview of the building, could hear the roof tiles popping and observed what he described as a “well ventilated respectable size fire”. He noted that firefighting operations were taking place on the northern side of the building and that this was not the most effective way of dealing with the fire.
8.20 A/StnO 1 felt he did not need to take command of the incident away from SubO 1 and the issue of who was in charge was not discussed. A/StnO 1's helmet and tunic rank markings were those of a SubO and not a StnO and as a result SubO 1 assumed they were of equal rank and in accordance with laid down protocols that he was in charge. Neither of the officers was wearing an incident commander’s tabard. Both formed the opinion that they would have to force the main entrance door to enable them to get an adequate supply of water onto the fire.
8.21 The firefighters riding in the back of 201, Jenkins, 6 and 5 exited the appliance and started to get to work. SubO 1 instructed Ff 5 to take the main jet and get it to work against the northern side of the building. He was assisted by Ff 6 who then traced the hose back to Ely’s pump and asked for “water on” before returning to the jet. Whilst he was performing this task he became aware that some of the crew were attempting to gain entry via the main entrance, but he was not able to identify who they were.
8.22 At first the water pressure to the jet was poor so Ff 5 returned to the pump to ask for an increase in pressure. The pump operator, Ff 1 informed him that until they had water from the hydrant the hose reel had priority. On his way back to the branch he also saw crew members who he could not identify trying to gain entry via the main entrance.
8.23 After putting on his fire kit Ff 4 the driver of 201, went to the back of his pump where he was asked by A/StnO 1 to get a hose reel jet off the appliance. As he started to pay out the offside hose reel Ff Jenkins took the hose reel branch from him and approached the front of the building.
8.24 At the front of the building was the main entrance. It consisted of a purpose built security door constructed of steel and had three locks, one each at the top, middle and bottom. A/StnO 1 started to force the door using a sledgehammer. As he was doing this, Ff Jenkins was standing near by, but away from the door with the hose reel jet. SubO 1 was also in the same area.
8.25 After paying out the hose reel, Ff 4 returned to the cab of Barry’s appliance in order to engage the pump. As he was returning to the rear pump locker he viewed A/StnO 1 attempting to force the door and decided to go and help. As he approached he saw a long handled sledgehammer on the floor. He picked it up and
Page 18 of 37 Published September 2004 started to hit the door. He continued to do so until he considered it was loose enough in the frame to enable it to be opened using a hooligan tool. At that point he returned to the pump and increased the water pressure to the hose reel which Ff Jenkins was holding.
Not to Scale ● ● 521 N H Toilets Ff 1
Assembly Area A/StnO 1 & SubO 1 Lobby Ff 3 J
Kitchen Ff 4
Ff 2 Ff 6 & Ff 5 201 LP ● ●
Figure 6 ~ Deployment of Ely and Barry crews at time when main entrance door is opened.
8.26 It is not possible to determine exactly how long it took to force the door but all of those involved confirmed that it took many strikes with the sledgehammer before it finally failed. At the point when A/StnO 1 finally opened the door using the hooligan tool, Ff Jenkins (with the hose reel), SubO 1 and Ff 3 (who had finished putting in the hydrant) were standing nearby. All three crew members described the conditions in the lobby as being clear of smoke and with the exception of flames starting to penetrate from the assembly area around the upper half of the double doors, the lobby was clear of fire.
8.27 A/StnO 1 instructed Ff Jenkins to play some water onto the lobby ceiling, this was to check its stability and ensure nothing was likely to come down on them. Ff Jenkins advanced towards the doorway checking the water supply to the hose reel as he went. He positioned himself outside the building to the right of the doorway and directed water in through the opening. At this point Ff 3 heard Ff Jenkins ask A/StnO 1 “shall I go in” but he did not hear any response. The officer has no recollection of this conversation. Ff 3 was then instructed by the A/StnO to run out traffic tape across the road at the front of Barry’s pump; at this stage Ff Jenkins had not entered the building.
Page 19 of 37 Published September 2004 Photograph 5 ~ Showing location of the first hydrant connected to Ely pump and the lamp post to which traffic tape was tied (both arrowed). NOTE: in this photograph the building has been demolished but the railings follow the same lines as the buildings external walls.
8.28 During the period when the front door was being forced, fire fighting operations were confined to the northern side of the building. Following connection to the hydrant the water supply improved enough to supply both the hose reel being used by Ff 2 and the main jet being used by Ff’s 5 and 6 Ff 5 reported seeing fire starting to break through the middle of the roof over the entrance lobby (see photograph 6) and being aware that crews were working in that area re-directed the main jet onto that part of the building. In a short space of time the flames on the main roof started to become more significant and the main jet and hose reel changed positions. This resulted in the reel covering the lobby roof and the main jet the main roof.
8.29 Shortly after the door had been opened, SubO 1 moved away to observe activities on the northern side of the building. He noted that fire had started to breakout through the gable end of the main roof and he shouted to one of the firefighters to direct water onto that area (see photograph 6). In time, the jet was further re-positioned as the fire spread eastwards along the main roof.
Page 20 of 37 Published September 2004 A B
Photograph 6 ~ Point A area where Firefighters 5 and 6 saw fire and point B area where Sub Officer 1 saw fire.
8.30 When SubO 1 returned to the front of the building Ff Jenkins was a couple of steps inside the doorway with the hose reel and A/StnO 1 was crouched down on the threshold.
Not to Scale ● ● 521 N H Toilets Ff 1
Assembly Area A/StnO 1 SubO 1 J
Kitchen
Ff 3
Ff 6 & Ff 5 Ff 2 Ff 4 201 LP ● ●
Figure 7 ~ Deployment of crews at time of explosion.
Page 21 of 37 Published September 2004 8.31 At this point the explosion occurred which created a fireball which came out of the front of the building. SubO 1 who was at the front of the building but away from the entrance door became engulfed in the fireball. He immediately ran to the back of Barry’s pump where he applied water to his face in attempt to stop the burning. A/StnO 1 who was also engulfed in the fireball, but to a lesser degree, retreated away from the entrance door.
8.32 Ff’s 5 and 6 were working with the main jet on the northern elevation of the main roof and the blast caused them to retreat as far as the perimeter wall. As they did the jet reaction caused them to struggle with the branch, but they quickly regained control and recommenced putting water onto the fire.
8.33 Ff 4 was walking to the cab of Barry’s pump with the intention of turning on the rear radio speaker. He was halfway down the side of the vehicle when the blast caused him to duck down. Ff 2 who was working on the northern elevation towards the front of the building, saw both the SubO 1 and the A/StnO running towards the pavement and fearing they may be on fire, he ran over with the hose reel.
8.34 Ff 3 was tying traffic tape to the back of Barry’s pump and was facing the building. After the blast he ran over and joined A/StnO 1 and Ff 2 The A/StnO entered the front door followed by Ff’s 2 and 3 they found Ff Jenkins lying facedown, motionless on the floor. The A/StnO and Ff 2 grabbed his shoulders and Ff 3 his legs. Together they “manhandled” him to outside the building and placed him on the ground. From here they moved him to a safer location on the pavement adjacent to the rear of Ely’s pump.
8.35 There is a conflicting account of who entered the building to rescue Ff Jenkins. The witness accounts of A/StnO 1 and Ff’s 2 and 3 support the sequence of events described in paragraph 8.34, however Ff 4's account differs. He recalls being the first to re-enter the lobby and assisting in moving the casualty to outside, at which point he left his colleagues, ran over to Barry’s pump and sent a message to Brigade Control requesting an ambulance.
8.36 Ff 1 was at the rear of Ely’s pump putting on the remainder of his fire kit and he saw some crew members entering the building. He assumed that someone was injured and likely to need medical attention so on his own volition sent an assistance message to Brigade Control at 01:25 hrs and 5 seconds.
521 521 over. Control 521 go ahead over. 521 521, make ambulance over, firefighter down 521. Control 521 received, will comply, SB out.
Page 22 of 37 Published September 2004 8.37 Following an initial assessment of the casualties injuries A/StnO 1 instructed Ff 2 to get a resuscitator from one of the pumps. SubO 1 started checking for a pulse and at the same time, instructed someone to call for an ambulance.
8.38 At 01:25 hrs and 30 seconds Ff 4 sent a message to Brigade Control requesting the attendance of an ambulance.
201 SB 201 over. There followed a 9 second pause. 201 SB 201 over. Control Go ahead over. SB 201, request immediate attendance of ambulance personnel 201 immediately, firefighter down, large explosion in building, 201 over. Control 201 received, do you require any further brigade assistance over? 201 Will advise, standby over. Control SB to standby over.
8.39 These requests for assistance were relayed to Ambulance Control and they mobilised an ambulance to the scene at 01:26 hrs and 32 seconds. After sending the radio message, Ff 4 returned to SubO 1 who was at the side of the casualty, and relayed Brigade Controls enquiry. The SubO gave him an assistance message to send, it was transmitted at 01:26 hrs and 52 seconds.
201 SB 201 over. Control 201 go ahead over. 201 Make pumps 4 over, firefighter seriously injured over, Control Received SB out.
8.39 Brigade Control actioned this request for assistance by sending the fourth pump, 512, from Central Station. It booked mobile to the incident at 01:30 hrs and 34 seconds.
8.40 At this point, there were five crew members attending to the casualty, either involved in resuscitation or in trying to stem the bleeding. These attempts continued for several minutes with the ambulance arriving on scene at 01:30 and 32 seconds at which point the paramedics took control.
8.41 After helping to move the casualty to the pavement Ff 3 retrieved the hose reel from the entrance lobby and proceeded to use it to attack the fire from outside the building. Ff 6 left Ff 5 on the main jet and went to see if he could render any assistance with the casualty. Realising that everything possible was already being done, he rejoined Ff 5
Page 23 of 37 Published September 2004 8.42 Penarth’s pump arrived at the scene at 01:30 hrs and 57 seconds followed by Centrals second pump at 01:36 hrs and 58 seconds. Both crews were committed to firefighting operations which entailed obtaining additional water supplies and getting various jets and ground monitors to work.
8.43 Temporary Assistant Divisional Officer 1 booked in attendance at 01:42 hrs and he remained in command of firefighting operations until the arrival of Temporary Divisional Officer 1 at 02:09 hrs.
8.44 The ambulance left the scene with Ff Jenkins and A/StnO 1 at 01:43 hrs and 32 seconds and arrived at the Accident and Emergency Unit of the University Hospital of Wales at 01:48 hrs and 32 seconds. SubO 1 was relayed to the same medical unit by a fire officer in his car.
8.45 Shortly afterwards, StnO 2 and Senior Divisional Officer (SDO) 1 arrived at the hospital to act as liaison officers. At approximately 02:13 hrs, medical staff confirmed that Ff Jenkins had been pronounced dead. SDO 1 immediately relayed this information to Brigade Control via mobile phone.
8.46 The Stop message for the incident was sent from Temporary Divisional Officer 1 to Brigade Control at 03:36 hrs.
Page 24 of 37 Published September 2004 9 NARRATIVE OF EXPLOSION
9.1 The explosion resulted in three Fire Service Personnel being injured. Ff Jenkins, who suffered fatal injuries, was carrying out firefighting operations with a hose reel in the entrance lobby to the building. A/StnO 1 was outside the building close to the front entrance door, probably on the threshold. The exact location of SubO 1 can not be confirmed however it is known that he was facing south and at the front of the building somewhere between it and the boundary wall which adjoined the pavement.
9.2 The accounts given by Ff’s 2 5 and 3 suggest that in the minutes leading up to the explosion the fire was growing in intensity. It had broken through both the roof over the main assembly area and on the north side of the lobby roof (see photograph 6). Smoke was also issuing from the eaves of the main roof and the fascia boards on the gable end at the front of the building. However the lobby area was clear of smoke and with the exception of flames starting to penetrate from the assembly area around the upper half of the double doors, the room was clear of fire.
9.3 The entrance lobby was 3.8m by 2.6m with a ceiling height of approximately 2.4m. The internal partition walls were constructed from timber and plasterboard and the ceiling was made up of sheets of fibreboard attached to timber floor joists. It had five doorways, a main entrance, kitchen door, double doors to the assembly area and the remaining two doors provided access to the toilets. Above the lobby in the roof void was a small storage area which consisted of timber floorboards laid onto joists. Access to this area could be gained via a hatchway in the main assembly area.
9.4 The explosion caused significant structural damage. Some of the external cladding was forced away from the front of the building with such power that timber fragments measuring up to 15cm in length were found up to 25m away. About a third of the tiles on the southern side and all of the tiles on the northern side were propelled from the lobby roof . The internal partition walls were still in place although some had suffered impact damage probably caused by flying debris. The entire fibreboard ceiling had come down including the light fittings and the remains of several ceiling joists and floorboards were either lying on the floor or hanging down into the entrance lobby. There was no evidence of fire or smoke damage to the ends of these timbers and their failure was consistent with being forced downward from above. The attic storage area had also suffered significant damage from fire.
Page 25 of 37 Published September 2004 Photograph 7 ~ Showing damage to front of building caused by explosion
Photograph 8 ~ Showing partial loss of tiles on southern pitch of lobby roof.
Photograph 9 ~ Showing total loss of tiles on northern pitch of lobby roof.
Page 26 of 37 Published September 2004 9.5 Ff Jenkins was found lying face down in the lobby area with his feet inside the kitchen doorway and his head towards the main entrance door. His helmet had come off and was on the floor near to the kitchen door. It had suffered significant impact damage which had resulted in the visor and harness adjuster coming away. Timber fragments were found near the crown of the helmet and there was a scrape on the helmet badge which went from the top point of the eight pointed star down towards the bottom. The damage to the helmet is consistent with a blow from the front and above.
Photograph 10 ~ Showing impact damage to front of helmet including, absence of visor, scrape to badge and timber on crown of helmet (arrowed).
9.6 During discussions with the Home Office Pathologist Dr. 1 it was confirmed that Ff Jenkins had suffered massive internal injuries to the front and upper area of his head. She expressed the opinion that they were consistent with being struck with considerable force by a flat object. There were also ‘percussion’ type injuries to the lungs which would indicate that he was in close proximity to the centre of the blast.
9.7 Hanging from the ceiling, partially supported by a damaged floorboard, were the remains of a 96lb (approximately 45kg) Liquid Petroleum Gas cylinder. It was red in colour which would indicate that it contained propane gas. Although it had suffered catastrophic failure and had split along its length, the base was intact and was marked with a serial number. From this it was possible to establish that it was manufactured for Calor in January 1971 by Van Lear of South Africa.
Page 27 of 37 Published September 2004 Photograph 11 ~ LPG cylinder suspended from ceiling.
Photograph 12 ~ Lobby area post explosion, LPG cylinder is top centre
9.8 The shoulder neck and valve grouping of the cylinder were found in the roof space approximately 2m away from the main body. The test recording disc was damaged to the point that it was not possible to obtain any information from it. There were two holes in the cylinder shoulder which would indicate a burst from within the cylinder. This would support the theory that the cylinder was under pressure during the fire. Forensic examination determined that the valve was in a closed position. It is common practice in the United Kingdom for these cylinders to be fitted with a pressure release valve either at time of manufacture or during periodic testing. The absence of such a valve would suggest that the cylinder had not been tested for over 10 years. Propane gas is normally stored at 7 bars and pressure release valves are usually designed to actuate at 26 bars. Normally when a cylinder is exposed to fire, the valve is able to dissipate the internal pressure at a greater rate than it is increasing, thereby preventing it from exploding.
Page 28 of 37 Published September 2004 Photograph 13 ~ Top of cylinder showing holes Photograph 14 ~ Modern valve with pressure (arrowed) test disc and valve. release valve (red).
9.9 At sometime the cylinder became exposed to the fire. The resultant heat would have caused the liquid gas to boil and convert to a vapour. This would have resulted in an over pressurisation of the cylinder (exacerbated by the absence of a pressure release valve) sufficient to cause it to fail. There would then have been a release of gas which would have ignited resulting in a fireball. This phenomenon is referred to as a Boiling Liquid Expanding Vapour Explosion (BLEVE).
9.10 The size and duration of the fireball are dependent on the quantity of available gas but 1 would normally only last a few seconds. As an example 7 /2 kg of LPG released from a bursting cylinder would typically produce a fireball approximately 11m in diameter. It would remain this size for about 1.2 seconds at which point it would cool rapidly and start to lift of the ground. (The Society of Fire Protection Engineers, Handbook of Fire Protection Engineering, third edition).
9.11 A tripod, believed to be part of a gas powered lamp was on the lobby floor with one end resting on electrical cables which had originally run in the ceiling void. This would indicate that prior to the explosion the tripod had been above the entrance lobby in the roof space. Towards the centre of the room were the remains of a gas powered flood lamp.
Page 29 of 37 Published September 2004 Photograph 15 ~ Location of tripod and gas lamp (both arrowed).
9.12 Both A/StnO 1 and SubO 1 suffered facial burns. The SubO was burnt on the left hand side of his face which is consistent with him walking across the front of the building from north to south. The A/StnO suffered burns to the right hand side of his face and although he was closer to the centre of the blast his injuries were less severe to those experienced by the SubO.
9.13 The structural damage to the roof, timber cladding and floor above the entrance lobby would indicate that at the time of the explosion the cylinder, gas lamp and tripod were in the attic space directly over the entrance lobby and slightly north of the building centre line. This is also supported by the injuries to the three firefighters and would account for the variance in the injuries to A/StnO 1 and SubO 1 If the centre of the blast had been at first floor level it is likely that the majority of the fireball exited the building through the opening made by the explosion in the front of the building and thus bypassed A/StnO 1
Page 30 of 37 Published September 2004 Assembly Room
Tripod
Approx location of Floor Joists cylinder at ceiling level Toilet
3.8m
Kitchen
Toilet Helmet Visor
Floodlight Floor Joists Main Entrance 2.8m
Figure 8 ~ Plan of accident scene ~ Not to Scale
Page 31 of 37 Published September 2004 10 SUMMARY OF FIRE INVESTIGATION REPORT
10.1 The investigation into the cause of the fire began shortly after firefighting operations were completed and concluded four days later on the 26th May 2004. It was jointly conducted by South Wales Police Scenes of Crime Unit, The Forensic Science Service and South Wales Fire and Rescue Service. As indicated the investigation started at approximately 02:00 hrs on the morning of the incident but this was confined to an observational examination of the scene, the investigation proper did not start until after daylight.
10.2 The building had been left unsecured for a considerable period and children and youths had been seen playing in the building for most of the day prior to the fire. Witness accounts established that the fire started sometime between 00:15 hrs and 01:00 hrs. The first firefighting crews arrived at the scene at 01:13 hrs at which stage the building was significantly involved in fire. The investigation concluded that the fire was not a smouldering type fire and therefore it probably started closer to 01:00 hrs.
10.3 There appeared to be more than one seat of fire and consideration was given to this being caused by radiated heat. However, this theory was discounted and the opinion formed that there was a second point of origin where the fire had started.
10.4 The Hydrocarbon Detector Dog was deployed and it indicated three locations where accelerants may have been present. Further examination confirmed the presence of white spirit in the north east corner of the assembly area but analysis of the other two areas was less conclusive and it was decided these may have been due to the presence of pyrolites resulting from partially burnt pieces of furniture.
10.5 During the investigation, the team considered many possible accidental causes for the fire including the presence of self heating materials, electrical and careless disposal of smoking materials all of which were eliminated.
10.6 In conclusion the investigation formed the opinion that there was more than one point of origin and the most likely cause was deliberate ignition.
Page 32 of 37 Published September 2004 Photograph 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.
Page 33 of 37 Published September 2004 11 CONCLUSIONS AND RECOMMENDATIONS
11.1 Conclusion One ~ Explosion
11.1.1 Firefighter Jenkins died from injuries he sustained after being exposed to an exploding LPG cylinder. The cylinder was out of sight and in an attic storage area above where he was working. There was no evidence or information available to firefighters at the scene to suggest the presence of the cylinder.
11.2 Conclusion Two ~ Incident Commander
11.2.1 On the night of the incident and in accordance with brigade protocols, SubO xxxxxxx was acting up to the rank of StnO. When he arrived at the scene he felt that SubO 1 had control of the incident and that matters were being dealt with adequately and consequently he decided not to relieve him of command.
11.2.2 The Acting Up policy does not address the issue of identification of rank and therefore A/StnO 1 was wearing the rank markings of a SubO. As a result SubO 1 believed that they were of the same rank and that he was the Incident Commander.
11.2.4 Recommendation. The current Acting Up policy emanates from the old Grey Book (Conditions of Service) and will not be included in the new version which is soon to be published. In light of this change, coupled with the impending move from Ranks to Roles and the introduction of Integrated Personal Development the need for such a policy should be reviewed. Consideration should also be given to the appropriateness of requiring an individual to operate at a different level of responsibility from one day to another. In the interim period, the brigades expectations of an officer holding an acting rank must be made clear and the issue of how they are identified on the fireground must be addressed.
11.2.5 Recommendation The South Wales Incident Command System should be amended to clarify when it may be acceptable for an officer not to take command of an incident from the existing Incident Commander.
Page 34 of 37 Published September 2004 11.3 Conclusion Three ~ Command and Control
11.3.1 There was no disagreement of who was the Incident Commander, it was SubO 1 Furthermore there was agreement between the two officers about how best to deal with the incident, particularly regarding the need to force open the front door to enable more water to be applied to the fire.
11.3.2 The incident was under control and every firefighter was performing a task in accordance with instructions given to them by either SubO 1 or A/StnO 1
11.4 Conclusion Four ~ Dynamic Risk Assessment
11.4.1 There was a suitable and sufficient Dynamic Risk Assessment carried out and its findings were used to influence firefighting operations1.
11.5 Conclusion Five ~ Tactical Mode
11.5.1 A tactical mode was not declared at the incident. A/StnO 1 evaluated the conditions in the lobby and determined that it was safe to enter. He had no way of knowing that there was a LPG cylinder in the attic storage area.
11.5.2 Recommendation Tactical mode protocols are an integral part of the South Wales Incident Command System. The purpose of this command system is to provide greater co-ordination at an incident and together with Dynamic Risk Assessment to assist in developing safe systems of work. The importance of implementing the command system at every incident, in particular the purpose of declaring a tactical mode, should be emphasised during initial and continuation training for both operational managers and firefighters.
1 At the time of signing this report, the brigade were unable to locate the Dynamic Risk Assessment training records for Sub Officer 1 although they are confident he received the training.
Page 35 of 37 Published September 2004 Appendix A
Summary of Significant Timings.
Times Message
01:07:37 Initial call to Brigade.
01:08 Bells down.
01:10:30 Ely mobile.
01:10:45 Barry mobile.
01:13:27 Ely in Attendance.
01:15:30 From Sub Officer 1 ~ Make Pumps 3, fire in large detached building.
01:17:38 Penarth mobile to incident.
01:18:57 Barry in Attendance.
01:25:05 Ambulance required Firefighter injured.
Require Ambulance immediately, Firefighter down large explosion in building ~ 01:25:30 response from Brigade Control, Do you want any brigade assistance?
01:25:32 Ambulance Control receives call from Fire Control.
01:26:32 Ambulance mobile to incident.
01:26:52 Make pumps 4 Ff seriously injured.
01:28:54 Request for ETA of ambulance.
01:29:34 Central mobile incident.
01:29:49 ETA of ambulance given
01:30:32 Ambulance in attendance.
01:30:57 Penarth in Attendance.
01:36:58 Central in Attendance.
01:40:35 Sub Officer 2 ~ request to increase water pressure.
Page 36 of 37 Published September 2004 Times Message
01:42 Temporary Assistant Divisional Officer 1 in attendance.
01:43:32 Ambulance mobile to University Hospital of Wales.
01:48:32 Ambulance in attendance at University Hospital of Wales.
02:13:53 SDO 1 contacts Brigade Control to confirm death of Firefighter Jenkins
02:09 Temporary Divisional Officer 1 in Attendance.
03:16 Stop message sent from Temporary Divisional Officer 1
NOTE: The timings for the Ambulance (in italics) have been adjusted to reflect a time differential between the clocks in the respective control rooms. On the night of the incident this differential was a minimum of 32 seconds.
Page 37 of 37 Published September 2004