FIRE AT THE DETENTION CENTRE SCHIPHOL OOST 26th October 2005 The Hague, 21st September 2005, project number M2005CH1026-1 The reports of the Dutch Safety Board are public. All reports are also available on our website www.safetyboard.nl 1 THE DUTCH SAFETY BOARD The Dutch Safety Board has been set up under statute law with the responsibility to investigate and establish what the causes or probable causes are of individual or categories of occurrences in all sectors. The sole objective of such an investigation is to prevent future accidents or occurrences and, if the results of this should give cause to do so, to attach recommendations to these findings. The organization consists of a Board with five permanent members and has a number of permanent committees. Specific advisory committees are formed for specific investigations. A staff of investigators and secretarial reporters support the Dutch Safety Board. N.B: This report is published in both the Dutch and English language. In the event of conflict in interpretation, the Dutch text will be deemed binding. Board Chair prof. Pieter van Vollenhoven Vice-chair J.A. Hulsenbek Ms. A. van den Berg prof. dr. F.J.H. Mertens dr. J.P. Visser Advisory committee Chair Ms. A. van den Berg J.A. Hulsenbek J.G.M. Alders J.D. Berghuijs Ms. A.H. Brouwer-Korff Prof. dr. B.P.M. Gersons Project manager: D.J. Smeitink Visitors address: Anna van Saksenlaan 50 Postbus 95404 2593 HT The Hague 2509 CK The Hague The Netherlands Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077 Internet: www.safetyboard.nl 2 THE DUTCH SAFETY BOARD CONTENT The Dutch Safety Board has been set up under statute law with the responsibility to investigate 1 INTRODUCTION ............................................................... 16 and establish what the causes or probable causes are of individual or categories of occurrences in all sectors. The sole objective of such an investigation is to prevent future accidents or occurrences and, if the results of this should give cause to do so, to attach recommendations 2 FACTUAL INFORMATION .................................................. 18 to these findings. The organization consists of a Board with five permanent members and has a number of permanent committees. Specific advisory committees are formed for specific 2.1 Reasons for the construction of the Detention Centre Schiphol-Oost .............18 investigations. A staff of investigators and secretarial reporters support the Dutch Safety Board. 2.2 Specific features of the Detention Centre Schiphol-Oost ..............................18 2.3 Cell construction administered in K Wing ..................................................19 N.B: 2.4 Personnel and organization .....................................................................21 This report is published in both the Dutch and English language. In the event of conflict in 2.5 Switch boards and fire alarm alerts ..........................................................21 interpretation, the Dutch text will be deemed binding. 2.6 The cell occupants in the Detention Centre Schiphol-Oost ...........................21 2.7 Organization of fire fighting for buildings at Schiphol ..................................22 3 COURSE OF EVENTS ......................................................... 24 3.1 Introduction ..........................................................................................24 Board 3.2 The start of the fire and the rescue action taken by the guards ...................24 Chair prof. Pieter van Vollenhoven 3.3 Development of the fire and arrival of the Fire Brigade following Vice-chair J.A. Hulsenbek cessation of guards’ rescue attempt .........................................................30 Ms. A. van den Berg 3.4 Subsequent action of the fire brigade after 00.30 hours .............................34 prof. dr. F.J.H. Mertens 3.5 Identification of the deceased..................................................................37 dr. J.P. Visser 4 FRAME OF REFERENCE ..................................................... 38 Advisory committee Chair Ms. A. van den Berg 4.1 Introduction ..........................................................................................38 J.A. Hulsenbek 4.2 Relevant legislation and regulations .........................................................38 J.G.M. Alders 4.3 Supplementary standards and directives (unofficial regulations) ..................43 J.D. Berghuijs 4.4 Discharge of individual responsibility for safety management .......................43 Ms. A.H. Brouwer-Korff Prof. dr. B.P.M. Gersons 5 THE PARTIES INVOLVED AND THEIR RESPONSIBILITIES 46 5.1 The Ministry of Justice ............................................................................46 Project manager: D.J. Smeitink 5.2 The Ministry of Spatial Planning, Housing and the Environment ....................50 5.3 The Ministry of the Interior and Kingdom Relations (BZK) ...........................52 Visitors address: Anna van Saksenlaan 50 Postbus 95404 5.4 The Ministry of Defence and the Royal Military Constabulary (KMar) .............53 2593 HT The Hague 2509 CK The Hague 5.5 The Municipality of Haarlemmermeer .......................................................53 The Netherlands 5.6 Miscellaneous Inspectorates ....................................................................54 Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077 Internet: www.safetyboard.nl 6 ANALYSIS OF THE DEVELOPMENT OF THE FIRE, RESCUE EFFORTS AND FIREFIGHTING .......................................... 57 6.1 Introduction ..........................................................................................57 6.2 Specific analytical framework in relation to rescue efforts and firefighting ......57 (emergency) organization .......................................................................64 6.3 The interested parties and their responsibilities in relation to rescue and firefighting ....................................................................................64 6.4 Structural analysis .................................................................................65 6.5 Analysis of the start and development of the fire .......................................65 6.6 Analysis of the actions of personnel within the detention centre ...................76 6.7 Analysis of the fire brigade’s performance .................................................81 6.8 Specific conclusions: development of the fire, rescue and fire fighting ...........94 7 A NALYSIS OF THE DISCHARGE OF RESPONSIBILITIES IN RELATION TO THE CONSTRUCTION AND USE OF J AND K WING ................................................................. 96 7.1 Introduction .........................................................................................96 7.2 Specific analytical framework in relation to the construction and use of J and K Wing .....................................................................................96 2 3 7.3 The different parties and their responsibilities in relation to construction and use ..............................................................................99 7.4 Analysis of the discharge of their responsibilities by the Custodial Institutions Service ..............................................................................103 7.5 Analysis of the discharge of responsibilities by the Government Buildings Agency .................................................................................108 7.6 Analysis of the discharge of irresponsibilities by the Municipality of Haarlemmermeer .............................................................................116 7.7 Analysis of the underlying factors relating to the manner of construction and use ............................................................................119 7.8 Specific conclusions in relation to the construction and use of J and K Wing .123 8 RELIEF AND AFTERCARE ................................................ 126 8.1 Introduction ........................................................................................126 8.2 Relief and aftercare in the case of serious accidents and disasters ..............126 8.3 Specific analysis framework with regard to aftercare ................................129 8.4 Parties involved and their responsibilities regarding relief and aftercare ......133 8.5 Reconstruction and analysis ..................................................................136 8.6 Subconclusions regarding relief and aftercare ..........................................161 9 OTHER INVESTIGATIONS............................................... 164 9.1 Introduction .......................................................................................164 9.2 ‘Fire safety of detention centres’ (State Inspectorates) .............................164 9.3 ‘Fire in the Detention Centre Schiphol-Oost’ report (independent commission on municipal responsibilities) ...............................................166 10 SUMMARY OF CONCLUSIONS ......................................... 170 10.1 Conclusions with regard to the development of the fire, the rescue and fire fighting .........................................................................................170 10.2 Conclusions on responsibilities with regard to construction and use of J and K Wing ......................................................................................172 10.3 Conclusions with regard to relief and aftercare of persons involved .............175 11 RECOMMENDATIONS ..................................................... 177 4