) !) :J () () () () () Cj o o o \:J o 'Report of the o Brigade .Investigation o ',.' . llltO the ·Death of cJ ". .;"- .Firefighter Fleur Lonibard eJ o U u U ) ) ) } ~ ) \) (J AVON FIRE BRIGADE () (j (J () REPORT OF THE BRIGADE INVESTIGATION INTO THE DEATH OF (:J FIREFIGHTER FLEUR L01v1BARD (J on () Sunday 4th February 1996 at Leo's Supermarket U Broad Street Staple Hill \~ Bristol U Presented By the Brigade Investigation Team u © Chief Fire Officer, Avon Fire Brigade. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior permission of the Chief Fire Officer. (i) PREFACE This Report has been compiled for the Chief Fire Officer of Avon Fire Brigade. It represents the unfettered findings, conclusions and recommendations of the official Brigade Investigation Team following our comprehensive inquiries into the fatal fire at Leos Supermarket, Staple Hill, Bristol on 4th February 1996, which claimed the life of Firefighter Fleur Lombard. When the Terms of Reference for the investigation were agreed, the then Chief Fire Officer declared that the investigation should be rigorous, searching and open in its approach and leave no stone unturned in the quest to find out all of the facts. In presenting our findings, we have been conscious of the contentment expressed by the Home Office Inspectorate, the Health and Safety Executive and the Fire Brigades Union for their own initial inquiries to be served by this investigation. In conducting the investigation, we have addressed specific issues raised by the Health and Safety Executive which are covered in the Report and at the same time, attempted to harness and report on wider issues which we anticipated would be of particular relevance to the Home Office and the Fire Brigades Union within the Terms of Reference laid down. We have been mindful that the Report may have attracted a wider circulation amongst other interest groups who may not be conversant with the relevant policies, procedures and jargon applying in some of the areas that we have investigated. The tenor of the Report has therefore attempted to describe the appropriate practice or policy prevailing where necessary and then detail our findings in that context. We have been constantly impressed with the unqualified co-operation and openness of witnesses and others to whom we have spoken throughout the investigation and we wish to express our appreciation for their assistance and for the profes­ sional and technical expertise that we have drawn on from a wide range of organisations and individuals. Without their help, it would have been impossible to compile this Report. Signature Removed Signature Removed D W Hutchings QFSM Grad LF.E P G Shilton M.I.Fire.E Acting Deputy Chief Fire Officer Divisional Officer (Brigade Investigation Officer) (Assistant Investigation Officer) September 23rd, 1996 (ii) CONTENTS Section Page 1 SUMMARY 1 2 INTRODUCTION 2 2.1 Sequence of Events 2 2.2 Purpose of this Report 2 2.3 Police Investigation 3 2.4 Investigation Strategy 3 2.5 Sources of Evidence 3 2.6 Terms of Reference 4 3 THE PREMISES INVOLVED 5 3.1 Building History 5 3.2 Arrangement of Premises 5 3.3 Building Construction 5 3.4 Roof and Ceiling Construction 8 3.5 Meat Preparation Room 10 3.6 Legislative Fire Provisions 10 4 BRIGADE ATTENDANCES 12 4.1 Appliances Attending 12 4.2 Personnel Attending 13 5 INCIDENT RECONSTRUCTION 14 5.1 Scenario Before the Fire 14 5.2 Discovery of the Fire 14 5.3 Exit Door 15 5.4 Speed of Events 17 5.5 Fire Brigade Actions 18 6 CAUSE OF FIRE 29 6.1 Reporting Procedures 29 6.2 Seat of Fire 29 6.3 Conclusions about Cause of Fire 29 7 CAUSE OF DEATH 31 7.1 Custody of Deceased 31 7.2 Postmortem Examination 31 7.3 Recorded Cause of Death 31 7.4 Evidential Factors 31 8 FIRE DEVELOPMENT 32 8.1 Background 32 8.2 Route of Fire Spread 32 8.3 Heat Output 33 8.4 Crucial Factors 33 8.5 Fibreboard Ceiling 34 8.6 Supposed 'Flashover' 34 8.7 Fatal Effects 35 (iii) 9 GENERAL BREATHING APPARATUS PROCEDURES 36 9.1 Policy Guidance 36 9.2 Controlling Procedures 36 9.3 Breathing Apparatus Emergency 38 9.4 Use of Guidelines 38 10 BREATHING APPARATUS INVESTIGATION 40 10.1 General 40 10.2 Implementation of Emergency Procedures 40 10.3 Reporting Requirements 41 10.4 Examination of Sets and Equipment 42 10.5 Personal Protection Issues 42 A Breathing Apparatus Sets 42 B Firefighting Uniform 44 10.6 General Application of Procedures 46 10.6.2 Briefing 10.6.3 Personal Line Attachment 10.6.4 Main Guide Line 10.6.5 BA Emergency - Officer Responsibilities 10.6.6 Preservation of Breathing Apparatus Control Board 10.6.7 Supervision of Casualty 10.6.8 Breathing Apparatus Entry Control Procedures 10.7 T raining and Competence Standards 48 10.7.1 General 10.7.2 Recruit Training 10.7.3 Probationary Training 10.7.4 Statutory Training 10.7.5 Routine Training 10.7.6 Specialist Training 10.7.7 Core Progressional Training 10.7.8 Training in the Phenomenon of Flashovers 10.7.9 Risk Familiarisation 11 PERSONAL PROFILE - FLEUR LOMBARD 55 11.1 Status 55 11.2 Educational Qualifications 55 11.3 Professional Qualifications 55 11.4 Previous Employment 55 11.5 Leisure Activities 55 12 CONCLUSIONS AND RECOMMENDATIONS 56 12.1 General 56 12.2 Personnel 56 12.3 Breathing Apparatus Procedures 57 12.4 Command and Control 60 12.5 Training 61 12.6 Fire Safety 63 ACKNOWLEDGEMENTS 66 SUMMARY OF RECOMMENDA nONS 67 (iv) APPENDICES Incident Events Chart - (Pages 1-16) la Ff 9 Statement - (Page 17 of above) 2 FRS Cone Calorimeter Test Results - (Pages 1-10) 3 Duties of Entry Control Officers - Stage 1 - (Pages 1-3) 4 Incident Involving Wearer Distress - O&T 24.32 - (Pages 1-2) 5(a)(I) BA Set 359 BackpIate Assembly and Cylinder Report - (Page 1) 5 (a) (2) BA Set 359 Facemask and Ancillary Equipment Report - (Page 2) 5(a) (J) BA Set 359 - (Page 3) 5 (a) (4) BA Set 359 - (Page 4) 5 (a\S) BA Set 359 - (Page 5) 5 (b) Sketch Plan of Location of Recovered Breathing Apparatus Set remains - (Page 1) 5 (c) Report of Examination of Impounded Breathing Apparatus Set No 359 - (Pages 1-6) 5(d) Report of Examination of Impounded Breathing Apparatus Set No 363 - (Pages 1-7) 5 (e) Letter - North Safety products - 8th February 1996 - (Page 1) 6 Scientific Services Report on Breathing Apparatus Test Samples - 12th April 1996 - (Pages 1-2) 7 Diagrammatic Reconstruction of Breathing Apparatus Control Board - (Page 1) TABLES No Page 1 Scientific Services Test Results of Breathing Apparatus Samples 43 2 Personal Protection Equipment Worn by Firefighter Lombard 44 3 Forensic Test Results of Samples from Firefighter Lombard 45 4 Forensic Test Results of Samples from Firefighter 9 46 5 Probationary Training Scheme Key Result Credit Availability 49 6 Synopsis of Training Received 54 (v) 116 1 Summary 1.1 On Sunday, 4 February 1996, a fire occurred at 1.7 The enquiries made to investigate the incident Leo's Supermarket at Staple Hill, Bristol in which have extended beyond interviewing the Brigade personnel Firefighter Fleur Lombard, whilst inside the premises in attendance at the relevant time. The investigation has wearing breathing apparatus lost her life. The fire, the taken account of Police statements (to which the supposed cause of which is recorded as deliberate ignition, Investigation Team were afforded confidential access) ravaged through the building at about lunchtime whilst the photographs and video tapes from a number of sources, shop was open for trading. Firefighting and damping down forensic evidence, scientific test results, fire behaviour operations continued at the premises until the incident was specifications and data together with test data and other finally closed at about 1800 hours on Thursday, 8 February evidence from the Fire Research Station of the Building 1996. Research Establishment. Such evidence has allowed the fire scenario to be reconstructed with a high degree of 1.2 Immediately it became known that Firefighter accuracy which has led to the conclusion that Firefighter Lombard was missing, a full Breathing Apparatus Lombard died as a result of the effects of a massive flashover Emergency was instigated which quickly located the which generated temperatures in excess of 100Q°C. deceased firefighter who was recovered and passed to the care of ambulance paramedics. 1.8 In addition to establishing the circumstances surrounding Firefighter Lombard's death, the investiga­ 1.3 All breathing apparatus and ancillary equipment tion focused on the effects of the building construction and in use by the breathing apparatus team of which Firefighter the building materials together with the fireloading within Lombard was a member was impounded and the location the supermarket in an endeavour to identify any from which the deceased was recovered was also secured in­ contributory factors affecting the behaviour of the fire. In tact for later investigation. this respect, comments are made in the Report concerning the use of fibreboard ceiling panels and about the varied 1.4 The Chief Fire Officer ordered a full inquiry into roof pitches and void capacities in a building which had the incident, the details of which are the subject of this been increased in size over many years by extensions and Report. The enquiries that have been made into the interconnections to c;eate a growing retail sales area.