Fatal Accident Investigation – Full Report
Total Page：16
File Type：pdf, Size：1020Kb
Fatal Accident Investigation – Full report Into the deaths of firefighters John Averis, Ian Reid, Ashley Stephens and Darren Yates-Badley at Wealmoor (Atherstone) Ltd Hangars 1 and 2, Atherstone Industrial Estate, Atherstone on Stour CV37 8BJ Friday 2 November 2007 WARWICKSHIRE POLICE WARWICKSHIRE Fatal Accident Investigation – Full report Into the deaths of firefighters John Averis, Ian Reid, Ashley Stephens and Darren Yates-Badley at Wealmoor (Atherstone) Ltd Hangars 1 and 2, Atherstone Industrial Estate, Atherstone on Stour CV37 8BJ Friday 2 November 2007 1 © Fire Brigades Union First published by Fire Brigades Union Bradley House 68 Coombe Road Kingston upon Thames Surrey KT2 7AE 020 8541 1765 www.fbu.org.uk ISBN. 978-0-9930244-1-2 All rights reserved. Contents Foreword by Matt Wrack, FBU general secretary ...........................................................................................................3 Executive summary...................................................................................................................................................................................5 1. Introduction .............................................................................................................................................................................................13 2. Synopsis ...................................................................................................................................................................................................14 3. The building’s construction and its history...........................................................................................................................15 4. Sequence of events ...........................................................................................................................................................................20 5. Evidence collection.............................................................................................................................................................................73 6. Analysis of evidence: .........................................................................................................................................................................74 7. Conclusions .........................................................................................................................................................................................106 8. Recommendations ..........................................................................................................................................................................109 1 Preface Matt Wrack, FBU general secretary Firefighters John Averis, Ian Reid, Ashley Stephens and Darren Yates-Badley died at a fire in Atherstone on Stour, Warwickshire on 2 November 2007, the worst incident of multiple firefighter fatalities in the UK since the 1970s. The tragic deaths of these four firefighters in Warwickshire – together with other deaths across the UK – made 2007 an unprecedented year for firefighter deaths in recent times. Eight firefighters died while on duty in 2007 alone, the worst year since 1985. Since then firefighters have died at operational incidents in Central Scotland in 2008, Lothian and Borders in 2009, Hampshire in 2010 and Greater Manchester in 2013. The trend in firefighter deaths was downwards until the turn of the century. From 1997 until 2002 there was not a single recorded firefighter death at a fire anywhere in the UK. However, there has been an alarming upturn in recent years. Firefighter deaths at fires rose sharply in the years 2003-2007, and there have been further deaths since. This suggests that lessons are still not being learned. Alarmingly, it appears that there are factors which contribute to such tragedies but which are being repeated at subsequent incidents. This report is the FBU’s serious accident investigation (SAI) into the Warwickshire incident that occurred at Atherstone on Stour, Warwickshire on 2 November 2007. We have produced a very detailed full report, with a set of conclusions derived from the sequence of events, evidence collection, and analysis. Firefighters must be fully trained to deal with ever changing circumstances in order to remain safe at all times. The union also published a summary report earlier this year. The process of producing a final report has taken so long because of a lengthy and complicated legal action, as well as the heavy commitments of FBU officials involved. The purpose of the FBU investigation was to establish the causes of the death of the four firefighters by analysing the strategic planning of Warwickshire Fire and Rescue Service prior to the incident and the operations and techniques used during the incident. The FBU has a duty, as the union which represents firefighters throughout the UK, to investigate the causes (direct or underlying) behind any such incident in order to learn from it and attempt to prevent any reoccurrences. Firefighter safety and the ‘safe firefighter’ concept are at the core of the FBU’s thinking and have been generally welcomed and accepted by the wider fire sector and politicians alike. We want ministers in all four governments in the UK, as well as chief fire officers, fire authority members and other politicians, to focus on learning the lessons from the Warwickshire deaths. The FBU wants those key decision makers to take action on our recommendations, to ensure that the events are never repeated. We will continue to investigate incidents and publish reports to prioritise firefighters’ safety. FBU officials will be seeking meetings with key stakeholders to discuss our report and what can be done to improve firefighter safety. Our members do not go to work to die. Firefighters assess the risks and take carefully planned action to rescue people, to deal with the various incidents we face and to make communities safe. We have the right to demand the best possible procedures, training, equipment and resources to enable us to do our job safely, effectively and professionally. That should not be too much to ask. I would like to thank the FBU’s accident investigation team,AIT 1 AIT 2 and AIT 3 for their conscientious work, as well as FBU executive council’s health and safety specialists for their input. I am also grateful for the support and solidarity shown by FBU members in Warwickshire and across the UK, and thank all those FBU officials who have contributed to the investigation process. 3 Abbreviations ACFO Assistant Chief Fire Officer BA Breathing Apparatus BAECO Breathing Apparatus Entry Control Officer BAMCO Breathing Apparatus Main Control Officer CM Crew Manager DCFO Deputy Chief Fire Officer DRA Dynamic risk assessment DSUs or DXs Distress Signal Units EASE Emergency Air Supply Equipment ECB Entry Control Board ECO Entry Control Officer ECP Entry Control Point FF Firefighter FSM Fire Service Manual GM Group Manager GFRS Gloucestershire Fire and Rescue Service PDA Predetermined attendance GFRS Gloucestershire Fire and Rescue Service HP Hydraulic platform HVP High Volume Pump HWFRS Hereford and Worcester Fire and Rescue Service IC Incident Commander IRMP Integrated Risk Management Plan RDS Retained firefighter SM Station Manager TIC Thermal Imaging Camera USAR Urban Search and Rescue WFRS Warwickshire Fire and Rescue Service WM Watch Manager WT Wholetime firefighter 4 Executive summary ES1 The deaths of four firefighters at Atherstone on Stour on the evening of 2 November 2007 were caused by a catalogue of organisational and systematic failings by Warwickshire Fire and Rescue Service. John Averis, Ian Reid, Ashley Stephens and Darren Yates-Badley paid the ultimate price for Warwickshire Fire and Rescue Service’s (WFRS) failure to provide safe systems of work for its firefighters. ES2 The detailed FBU investigation of the disaster found that WFRS failed to plan for such a fire and failed to assess the risk of fire at the premises – Hangars 1 and 2 at Wealmoor (Atherstone) Ltd. ES3 These failures meant that on the night of the fire: • The incident commander and crews attending the fire had no accurate information about the lay out and construction of the premises, and were therefore unable to locate the seat of the fire or assess the risks arising from its construction, including the risk of collapse. • Firefighters, particularly retained (part-time) firefighters, were not properly trained to fight this kind of fire. • The incident command system did not function correctly which resulted in confusion and indecisiveness about what action to take and who was responsible for decision making. • There was a lack of command support which resulted in no written recording of risk assessments during the operation and no monitoring of staff performance at the incident. • Guidelines on the use of breathing apparatus (BA) – including deployment of BA teams and recording reports of successive BA teams after they had been deployed – were not followed and so firefighters were put at unnecessary risk with tragic consequences; • There was failure to secure an adequate water supply to fight the fire. ES4 There were also operational concerns, including operation of a thermal image camera (TIC) and poor hose management. Before the fire No effective IRMP ES5 The disaster started prior to the incident with the failure by WFRS to deliver an effective integrated risk management plan (IRMP), which should have identified Hangars 1 & 2 as a significant risk to firefighters.