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FBU Region 9

FBU Health and Safety report concerning the fatal fire at Harrow CourtExecutive Summary and findings 1

FIRE BRIGADES UNION

EXECUTIVE SUMMARYand Findings

from the

FBU HEALTH&

SAFETY REPORT

Concerning the fatal fire at85 Harrow Court

Silam Road, Stevenage, Hertfordshire

FBU Region 9


Contents

Sections Number PageContents

Foreword

Brief Description of the Incident 1 4

Sequence of events 2 6

Executive Summary 3 43

Conclusion 4 48

Recommendations 5 50

FBU Region 9


Foreword

The Fire Brigades Union (FBU) produced a comprehensive Health and Safetyaccident investigation report into the fatal incident where two firefighters died at 85Harrow Court, Silam Road, Stevenage, Hertfordshire on 2nd February 2005. Thefollowing is not the full report, rather a selection of the main findings from the fullreport intended to provide a more readily digestible summary consisting of 60pages.

The FBU’s full report was submitted to the Coroner and as a consequence is a publicdocument. The full report contains 252 pages and 18 sections, covering a range ofrelevant matters including the fire safety features of the building, the sequence ofevents, PPE, training and standard operating procedures etc.

The aim of the investigation was to analyse the circumstances surrounding theincident and study the sequence of events leading up to, during, and immediately afterthis tragic accident so that we might determine the causes of the accident; prevent asimilar recurrence; and ensure the Health and Safety at work of all firefighters.

It was not the purpose of the FBU’s investigation to try and determine the origin ofthe fire.

The full report was compiled by Paul Stanbridge, the Hertfordshire Health and SafetyCo-ordinator in his capacity as the appointed Brigade Health and Safety Officialunder the Safety Representatives and Safety Committees Regulations 1977 (SRSC) asamended; Pete Matthews, the Regional Health & Safety Co-ordinator; and GrahamNoakes, the Regional Secretary for the East Anglia Region of the FBU.

The conclusions and recommendations were based on the information, evidence anddocumentation that was made available to the Fire Brigades Union and to the best ofour knowledge was accurate at the time of producing the full report. We emphasisethat any additional information subsequently becoming available could alter thefindings of this and any future reports.

We would like to thank all of those who have assisted us in the investigation and thecompilation of the FBU’s Health & Safety accident investigation report, in particularthe members of Hertfordshire Fire and Rescue Service and the families of thedeceased for whom this must have been an extremely, distressing and emotional time.

Keith HandscombExecutive Council MemberFire Brigades Union, Region 9

Signature Removed

FBU Region 9


1 Brief Description of the Accident

Hertfordshire Fire and Rescue Service received an emergency call just before 3.00AM on the 2nd February 2005. The caller stated that the fire was on the 15th Floor,Flat Number 89 Harrow Court and that there were people in the flat. He was sureabout this because he said, “he could hear them shouting”.

The Hertfordshire Fire and Rescue Service (HFRS) mobilised 2 pumping appliancesfrom Stevenage fire station with a total of 9 Firefighters, the Aerial appliancestationed at Stevenage was not mobilized.

When the initial appliances arrived the crews could see dark smoke coming from thewindows of a flat on one of the upper floors, but could not tell exactly which floor thefire was on.

The officer in charge (OIC) of the first fire appliance to arrive entered the buildingand was told by members of the public that the fire was on the 14th Floor, FlatNumber 85 and that there were people in the flat.

The first BA crew Ff Miller and Ff Wornham and their OIC, entered Harrow Courtand went directly up to Floor 14th using the lift carrying 1 length of hose, a hooligantool and a branch between them. When they arrived at Flat 85 there were signs of afire (smoke was coming from the gaps around the door).

Nevertheless they went up to the flat 89, checked that there was no sign of fire on the15th floor, and then returned to flat 85 on the 14th floor. Ff Miller and Ff Wornhamthen waited outside the flat whilst the OIC went back to the dry riser outlet to supplythem with water, when the OIC returned to flat 85 it was apparent that Ff Wornhamand Ff Miller had entered the flat.

Ff Wornham and Ff Miller entered the flat 85 without any water, and immediatelycame across who was in the hallway, they escorted him to safety, it wouldappear that they then re-entered the flat to find Ms Close when a major firedevelopment occurred. Ff Miller and Ms Close were caught by the full force of thisrapid spread of fire, whilst Ff Wornham managed to escape only as far as the lobbyoutside flat 85.

The second BA crew consisting of another 3 fire fighters carrying various items ofequipment went up to the 15th floor also using the lifts. On leaving the lift they saw nosign of fire so went down the stairs to the 14th floor, where they met the OIC of thefirst crew who was at this time trying to break the chain that was securing the dry riseroutlet.

The second BA crew went along the corridor following the original line of hose,which was not charged with water at this stage. The hose was then charged as theytried to enter the flat, however they were beaten back by the heat and smoke.

4 minutes into the incident the OIC of the initial attendance requested furtherassistance - Make Pumps 4.

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8 minutes approximately into the incident the OIC confirmed to HFRS fire controlthat there were persons reported and an ambulance was required.

12 minutes after the arrival of the first appliances on the scene, HFRS fire control wasinformed of the Breathing Apparatus Emergency (This message would only be usedto inform fire control that there was a “problem” concerning the fire fighters wearingbreathing apparatus).

The second BA crew went down the stairs to the 13th floor and across to the rear stairswhere they then tried to gain entry into the lobby out side flat 85. However once againthey where beaten back by the heat and smoke. It was at this point that they first sawone casualty who was lying on the lobby floor out side flat 85.

This is when they found Ff Wornham who was on his back with his legs towards thelanding door and his head towards the front door of flat 85, it appeared he was stuckto the floor and that he was tangled up in cabling. They tried to rescue him but wereunable to do so.

16 minutes after the first 2 appliances had arrived, the third and fourth fire appliances(Hitchin and Baldock) booked in attendance, more than 4 minutes after the initialBreathing Apparatus Emergency was declared.

On their arrival at the incident two further BA crews were instructed to go up to the14th floor immediately, on the way up to the 14th floor they past Ff on his waydown and when they arrived they relieved FF from the second BA crew whowas still trying to rescue Ff Wornham.

Between the 3rd and 4th BA crews they eventually managed to rescue Ff Wornham andcut him free, they then carried him down the rear stairs to the 13th floor, handed himover to the other crew members who then placed him in the care of the paramedics.Ff Wornham was then taken to Lister Hospital where he was pronounced dead.

The BA crews from Hitchin and Baldock then went back up to the 14th floor, re-entered the lobby and then continued the search for Ff Miller and Ms N Close. Theytried to advance with hose-branch, but it was too short. A further length of 45mm hosewas already flaked out and was then used to extend the branch.

The crews advanced into flat 85, crawling to keep low because of the intense heat.The first crew had a branch and were knocking down the fire as they moved forward.

It was during this search that they found two casualties in the main bedroom. Once ithad been confirmed that both casualties were deceased, a decision was made tocontinue with the firefighting operations and proceed with extinguishing the fire,whilst leaving the bodies in situ.

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2 The Sequence of Events

Introduction

The following narrative which details the events leading up to, during andimmediately after the fatal accident has been prepared on the basis of the information,evidence gathered from the scene and documents that have been made available to theFBU, we then dovetailed the individual references together to provide a detailedSequential Time Event Plotting (STEP) chart, starting at 02:55 when the first signs ofthe fire were noticed and ending at 04:28:21, in particular we looked at;

Recordings from the HFRS Emergency Fire Control Room, telephone calls and mainscheme radio transmission during the incident and copies of the incident log printout*CCTV footage from Harrow CourtPhotographsScientific reports,Video recordings of the BRE reconstruction tests.HFRS policies/proceduresTraining records of some of those personnel who attended the incident.

We were also provided with copies of video & audio recordings and statements takenfrom members of the public and interviews with the service personnel who attendedthe incident-primarily the crews of 230 and 231 (Stevenage’s fire appliances) and 320& 310 (Hitchin & Baldock’s first fire appliances) who attended the incident whomhave given their consent for the FBU to have copies of their interviews.

Although FBU Officials were not permitted to be present at any of these interviews,as they were carried out by the police as part of either their criminal investigation, orthose contracted out to the police as part of the Hertfordshire Fire & Rescue Service’sHealth and Safety investigation, there were also a number of further interviewsconducted by members of the Fire investigation team.

Other particulars contained in the narrative, other than those referred to above, are asa result of a number of subsequent interviews conducted by ourselves with membersof the public and service personnel.

Where we have used a pertinent point from any statement in compilation of thisnarrative it is shown in quotation marks and in italic font, a full summary of thestatements used are contained in the appendixes.’

With regard to the timings given in the narrative, we have been informed by HFRSthat there is approximately 07:06* minutes time lag between the CCTV footage andreal time as recorded by the HFRS Control System. The Computerised MobilisingSystem logs key operation times to the second during call handling and subsequentmobilisation of fire appliances.

The times relating to 999 emergency calls to the fire service and the HFRS mainsscheme radio transmission (Control to fire appliance) are recorded on a digital voiceoperated logging tape in the control room which records and can play back by date,time.

FBU Region 9


This system records times to the second of all emergency calls and all main schemeradio transmissions.

Furthermore there is also a slight discrepancy between the times shown on the Visioncomputerised log and the times shown on the hand written Dictaphone log. We wereinformed by HFRS in an e-mail dated 23 September 2005* that the reasons for thesedifferences are because of the time delay between the call being automatically loggedon to the system, and the control officer processing the data onto the ComputerSystem, which is not acknowledged until the end of the message once the controloperator ‘hits the return key’ therefore the more complex or detailed the message, thegreater the differential would be.

The e-mail* goes on to say that sometimes not all 999 calls and some repeat calls arelogged so there will be a incoming call time recorded, but no corresponding log to gowith that call, although it is “our procedures to log all calls.”

All the times given in this section are taken from the CCTV time adjusted accordingly-07:06 minutes to bring them back to real time as recorded by the HFRS Control, alsothe times and durations shown in relation to telephone and radio transmissions aretaken from the Harrow Court Dictaphone Telephone logs to allow for this timedifference to give an accurate chronological order of events.*

Where times are assigned to 999 calls to the brigade or to radio transmissions in thenarrative the time quoted is the time at which the call / transmission began.

Wednesday 2nd February 2005

the occupant of flat 85 Harrow Court had borrowed a number of tea lightsfrom his neighbour because his prepaid electricity meter had run outearlier that day, she has substantiated this fact in her statement to the police.

states in his police statement, that he placed two of the tea lights directlyon top of the television in the main bedroom and lit them with his cigarette lighter, heand went to bed between 23:00 and 23:30 and laid there chatting, the plan wasto blow them out before he went to sleep but unfortunately “we both fell asleepleaving them lit.”

02:55 Approximately, ’s, who’s flat, is directly above flat 85 states thatshe “heard noises coming from the flat below”, she described these noises “as a maleshouting”, “animal scratching” and “Then I felt the noise could be electricitysparking,” she then looks out of her bedroom window and “saw flames coming fromthe bedroom window of the flat immediately below us”.

the occupant of 95 Harrow Court, states that “he looked out of hislounge window and noticed black smoke coming out of the bathroom window of a flatbelow him” and phoned the fire brigade, also says that he could smellsmoke for several minutes before getting out of bed and going to the window.

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02:58:47 The British Telecom Operator connected an emergency call directly toHertfordshire Fire and Rescue Service (HF&RS) Command and Control Centre basedat Longfield, Stevenage; Control telephone log number 9491

Connecting ( 02:58:47 )

HFRS Operator Fire & Rescue Service

Occupant Hello, there is a fire at Harrow Court on the 15th floor,there’s smoke pouring out, the alarms haven’t goneoff though love.Caller cough’s

HFRS Operator Harrow Court? (very quietly)

Occupant Hello

HFRS Operator Harrow Court?

Occupant Harrow Court, yes

HFRS Operator Right, one second. (very quietly)

Occupant Ah Jesus, but…

HFRS Operator What road is it on?

Occupant It’s on the 15th floor, I’m just going to go down andthere’s people in there.

HFRS Operator What floor are you on?

Occupant I’m on the 16th floor, the floor above; I live in 95,Harrow Court.

Occupant Yes and I think the fire is number 89, I think it’s onthe 15th, I’m sorry but the smoke is so thick now, butI’m pretty sure it’s on the floor below me.

HFRS Operator Do you know if there are people inside the premises?

Occupant There is, I can hear them shouting.

HFRS Operator Right OK, that’s fine, we’re on our way sir

Occupant Right, thank you, goodbye

HFRS Operator Thank you, bye bye ( 03:00:01 )

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states that he went down to flat 89 on the 15th floor but realised hehad made a mistake when talking to the emergency Fire Control Officer; the fire wasactually below that on floor 14.

02:59 approximately, and all go down to the 14thfloor states in his statement to the police that he “tried the door handle ofnumber 85” he also states that, “I could not smell any smoke or hear any noise”however who was standing on the 14 floor landing looking to my lefttowards the front door of flat 85 states that she “saw smoke coming out of the door.”

03:00 states that she “set off the fire alarms by breaking the glass box”this was recorded by Redcare-who monitor the AFD system at Harrow court, as thebreak glass being activated on the 15th floor. Although they also believe that theautomatic detector heads in the common areas may have activated at exactly the sametime which indicates that smoke was now issuing out from flat 85 into the lobby areaoutside.

claims that she warned of the possibility of a ‘Backdraught orFlashover’ if he attempted to open the door to the flat.

03:00:42 When the emergency call was received from at 02:58:47 anew incident was ‘created’ on the Vision call out system by the HF&RS Fire ControlOperator once the address and nature of the call had been ascertained.

The histogram indicated the pre-determined attendance of two appliances and thenearest appliances using the automatic vehicle location system. The two nearestappliances were 230 and 231, from Stevenage Fire Station were mobilised.

The following is the detail sent to the station tele-printer:

The Incident Log ReportIncident Number 001693-02022005Time: 03:00:36Date: 02/02/2005Operator ID: STStation: C23Risk: CType: Flat Fire Persons ReportedAddress: Harrow Court, Stevenage, SG1 1JTDetails: 15th Floor-Fire believed to be in no 89OIC:

Caller:

03:00:36-03:02:17, T/LFf alerted the crews around the station usingthe internal loudspeaker system giving brief details of the incident, however she isunsure as to whether it was received as a ‘person’s reported’ incident.

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FBU Health and Safety report concerning the fatal fire at Harrow CourtExecutive Summary and findings

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T/LFf made a decision on 231 for the crew to rig in fire gear and donBA en-route as it was a ‘confirmed fire’ and Harrow Court was so close to the stationand “it is easier to take off BA than put it on,”* 231 left the station first followedclosely by 230, seconds later.

03:01:11 DO was informed by telephone of the incident.

03:01:35 appears in the right hand lift to descend to the ground floor,arriving in the foyer at 03:02:07.

03:02:17 LFf the Crew Commander in charge of 230 and T/LFfin charge of 231 both attempted to book mobile at the same time, the

Control operator acknowledged 230, as they came across clearer with their message.

T/LFf from 231 booked mobile again and an acknowledgement was givenby the Control Operator.

The crew for 231 that night was;

Officer –in-charge T/LFfDriver FfBA Wearer Ff Michael MillerBA Wearer Ff Jeff Wornham

The crew for 230 that night was;

Officer-in-charge LFfDriver FfBA Wearer FfBA wearer FfBA Entry Control Officer Ff

231 and 230 turned left out of Stevenage Fire Station into St Georges Way, left at theroundabout into Six Hills Way, next left into Homestead Moat, left again into CuttysLane, then right into Silam Road and a left turn into the Harrow Court flats.

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Fig 1

T/LFf states in her statements to the police. Whilst travelling to HarrowCourt she, “could see plumes of smoke coming horizontally out from one of the upperfloors, this was dark grey and looked heavy — This was a real incident. I radioed to

on channel 1 telling him that ‘it’s a job’ as suggested we ‘make pumps 4’.”Although this message was not acknowledge, and the Fire Control radio log recordsthe ‘make pumps 4’ message at 03.08.04 approximately 4 minutes latter.

Ff in 230 states “I saw heavy thick black smoke pumping from thewindows of a very high flat, which seems to be ‘sticking’ to the building”.

Ff states that he sees, “thick dirty dark grey smoke pumping out”.

LFf states in his interview that he could not see smoke or any product offire until appliance 230 arrives in the “forecourt” of Harrow Court.

T/LFf remembers using her hand held fireground radio whilst travellingalong Silam Road to inform LFf that “it’s a job” and “make pumps 4”,however she received no response and make pumps 4 was not received at FireControl, until 03:08:04.

03:02:43 A second emergency call was received from the occupant of flat 35,Control telephone log number 9492:

Fig 1 Map: route taken by both appliances from Stevenage fire station to harrow court flats

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Connecting (03:02:43)Call received-fire alarms sounding in the background

HFRS Operator Fire and Rescue ServiceOccupant The alarms are going off at Harrow Court, there is really

like a strong smell of smoke.HFRS Operator Are you phoning from number 35, is that correct sir?Occupant That’s right yeahHFRS Operator Any idea what floor it‘s coming from?Occupant I don’t know if it’s from outside or whether it’s from the

bin room or what.HFRS Operator Right, we are actually on our way nowOccupant Alright, thank youHFRS Operator OKOccupant Thanks, byeHFRS Operator Bye (03:03:11)

03:03:05 Herts fire control received a call from the Custodian Alarm Company,Control telephone log number 26234

Connecting (03:03:05)Call received-fire alarms actuating in the background

HFRS Operator Fire and Rescue ServiceCustodian Alarm Company, Custodian. We have a fire alarm for

you.HFRS Operator OK, where about is itCustodian The Stevenage Borough Council, Harrow Court, Silam

Road, Stevenage.HFRS Operator Eh, Eh, can you spell that, that road for me, S, A,Custodian (caller spells) S,I,L,A,M.HFRS Operator ( operator Spells) S,I,L.Custodian A,M, Silam RoadHFRS Operator Silam, right…….OK, that’s fine thank you very muchCustodian OKHFRS Operator OK, bye (03:03:54)

03:03:13 and made their way to the ground floor using the northstaircase to the ground floor.

03:03:20 Appliance 231 appears in the CCTV cameras and positions to the right ofthe main entrance facing the building.

03:03:25 Appliance 230 appears in the CCTV camera’s and positions behind 231facing the same direction.

03:03:22 Ff decided to position the first appliance, but was unsure as tothe hydrant location at this point. T/LFf asked Ff if itwould be wise to make pumps four at this stage, he replied that she should speak to

as it would be LFf ’s decision, as he was in overall chargeof the incident.31

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03:03:28 T/LFf tells Ff’s Wornham and Miller to get breaking in tools and a45mm hose and branch before leaving the appliance; T/LFf grabbed thebranch from the appliance herself, she felt she did not have time to pick up the liftkeys from the appliance.

03:03:32 and in the mainfoyer, waiting for the fire service to arrive.

Fig 2

tells T/LFf “The fire is in flat 85 on the 14th floor and there aretwo persons in there”.

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walks to the lifts, and is followehim at the right hand lift.

03:03:49 LFf booked bothHarrow Court, Control radio log number 279

Fig 2 Still photo copied from the CCTV footage of ,

Fig 3 Still photo copied from the CCTV footage of T/LFf

03:03:35 ,and

in the main foyer, talkingto T/LFf the first FireService person to enter HarrowCourt. opensthe doors for her as they areelectronically operated forsecurity purposes,and/or also speak toT/LFf

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03:03:47 T/LFf turns, holdsthe doors open and has a briefconversation with the CrewCommander of 230, LFfwho enters wearing the OIC surcoat,the conversation continues as he entersthe foyer.

Was the information given bywas not passed, at this time, to

LFf or to the other crew

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ing the fatal fire at Harrow Courtary and findings

d by LFf who stands beside

230 and 231 appliances in attendance at9797.

and talking to T/LFf

talking to the OIC LFf

members?

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LFf VI 230 231 in attendance, smoke issuing, over

Control Operator 230 231 In attendance received, VI to standby

03:03:47-03:04:02 T/LFf continues to hold the main door open, Ff JeffWornham enters the lobby carrying a haligan tool (breaking in tool).

Ff Michael Miller enters the lobby carrying a length of 45mm hose and his helmet,with a hand controlled branch, both walk towards the right hand lift.

T/LFf and Ff Miller both had hand held radios, Ff Wornham had two handheld radios. T/LFf was on channel 1 whilst it is unknown what channel FfMiller’s radio was on, Ff Wornham was also on channel 1 and possibly channel 3with the second radio he carried, although that is not confirmed.

LFf talks to Ff Wornham and T/LFf as they approach the liftlobby and gesticulates toward the right hand lift with his left hand.

03:04:02 All of the first crew members enter the right hand lift; looks intothe lift and points upwards as the lift door closes and begins to ascend to the upperfloor.

T/LFf believes the right hand lift will only go to even numbered floors andthe left hand lift will only go to odd numbered floors.

List of Equipment taken to the upper floor by the first BA crew:

1 x 45mm hose1 x Hand held branch4 x Hand held radios1 x Hooligan tool

03:04:04-03:04:31 LFf holds the main entrance doors open, Ffenters the flats carrying two rolled up 45mm lengths of hose and his helmet,

and wearing BA, he walks to the lift lobby and places the hose by the right hand lift.

Ff has a discussion with in the lift lobby and is joined by LFfFf enters main lobby wearing BA, carrying his helmet, a

haligan tool and a hand controlled branch, and makes his way to the lift lobby.

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03:04:17 Ff‘s Wornham and Millerdon their BA face masks and smokehoods as they are making their wayto the upper floor in the right hand


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Fig 4

03:04:30 Ff takes the Bolt croppers from under the arm of Ffas Ff is waiting to enter the main entrance to the flats, the door is closed, anda resident in the lobby opens the door for him.

Ff crops the padlock and gains entry to the dry riser inlet; however he doesnot return the bolt croppers to Ff

Ff is waiting in the lift lobby with and LFf as Ffwalks toward the main entrance across the lobby.

03:04:33 Ff walks towards the lift lobby wearing a BAECO surcoat and hishelmet carrying the BAECO board, thermal image camera, line bag and handcontrolled branch. These items are placed outside the left hand lift, before Ffreturns to the appliances for more items of equipment.

the resident of flat 84, which is situated across the lobby from flat 85,states that he was woken in a room “full of smoke” by a noise from a male person hebelieves was kicking at the door of number 85, he quickly dressed and decided he hadbetter “get out”.

He looked across the lobby to see smoke issuing from the top of the door and theletter box where the male person was or had shouted to the residents inside and thenwent away down the north stairs.

03:04:36 T/LFf steps out of the lift onto the upper floor after handing thebranch to Ff Miller.

03:04:39 Ff Miller steps out of the lift onto the upper floor, with his BA under air,wearing his helmet.

03:04:42 Ff Wornham steps out of the lift onto the upper floor, with BA under air, notwearing a helmet.

Fig 4 Still photo from the CCTV of Ff’s Wornham and Miller donning their BA in the lift

lift with T/LFf

Ff runs out hose toconnect the pump of appliance 231 tothe dry riser inlet situated to the righthand side of the main entrance door,the inlet was locked closed with apadlock and chain, the hose line wastwinned using two lengths of 70mmhose.

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03:04:48 Ff manoeuvres appliance 230 to place the pump bay towardthe pump bay of appliance 231.

03:04:48 Ff and Ff begin to put the equipment into the left hand lift.LFf holds open the left hand lift doors to allow equipment to be placedinto the lift.

03:04:59 Ff re-enters the flats with the First Aid kit, Mars (Manual andAutomatic Resuscitation System) and takes them to the lift lobby.

The following sequence of events is put together using extracts from thestatements made by T/LFf and residents from Harrow Court, whilst itdifficult to pin point the exact time of each event, the sequence starts once T/LFf

Ff Wornham and Ff Miller leave the lift on the upper floor at03:04:42.

T/LFf states that, after leaving the right hand lift on the 14th floor there is nosign of fire, although the audible fire alarm was sounding on this floor as it was in allareas of the flats, T/LFf Ff’s Wornham and Miller turned right and madetheir way towards the lobby outside flat 85.

As they passed the middle one bed roomed flat on the left of the corridor, a male cameout and T/LFf said, “What are you doing, get out”, and then continued tothe lobby.

When they arrived at the lobby outside flat 85 they were confronted with wispy darkgrey smoke coming from the top of the front door, T/LFf states in herinterview “which can be associated with a fire starved of oxygen”, but just to be sureof the address, very quickly, the three crew members go to flat 89 on the 15th floor,using the north stairwell, to check the premise in the initial emergency call from

to the Hertfordshire Fire & Rescue Service Control.

However in statement he says that; two Firefighters appeared on thestairs, behind them was a female firefighter, he believes they were climbing up pastthe 14th floor from the13th floor. attracted her attention as he could seewhat he believed were flames from behind the glass quarter light above the front doorof flat 85 and smoke was still issuing from the top of the door.

He goes on to say that; he informed the female Firefighter that the fire was,“definitely in there” and was aware of her calling the two Firefighters down to floor14 from the 15th floor, all three crew members were in the lobby between flats 84 and85, when decided to leave he believes the Firefighters were starting tomake a forced entry to flat 85, he exits along the corridor passed the lifts to the southstaircase and down the stairs.

T/LFf says that; she decides to get water to the flat and tells Ff’s Wornhamand Miller to “think about the breaking in gear, how to get in, getting ready to go inand to don up (masks on, all their safety kit on)”, and she would, “get water sortedout”, the haligan bar was left with them.

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T/LFf states that to her knowledge the Breathing Apparatus Entry ControlBoard was not set up until taken over by LFf from the Hitchin Appliance320, who mounted the south stairs at 03:22:49 and no formal Bridgehead wasestablished by her or any of her crew members.

Ff’s Wornham and Miller had not removed their BA tallies when T/LFf leftthem outside the door of flat 85 Harrow Court to “sort the water”.

T/LFf believes she met a resident coming out of the middle single bed flat tothe left of the corridor when making her way to the dry riser outlet, ( possibly flatnumber 83 ), T/LFf advised him to get out.

T/LFf states that she; runs through the corridor with the 45mm hose andbranch, back to the dry riser outlet in the south stairwell saw that there was a chainpadlocked around it. She immediately realised that there was a problem as there wasnothing to cut through this chain, the bolt croppers were needed.

She then runs out the length of 45mm hose along the corridor, which is rapidly fillingwith dark black smoke, towards the lobby outside the fire flat.

the resident of flat 82 says, in her statement to the FIT that she iswoken up by the fire alarms at about 03:20 according to her alarm clock, although it isusually between 5 and 10 minutes fast, when asked if and how long she slept throughthe sounding alarm before waking she said “may be a minute no more” and that shewas a light sleeper.

says that she then looks out of her flat she sees a layer of smoke anda hose running along the ground heading towards flat 85, and, “to her left there was afire lady there,” “She had long blonde hair I think I remember, in a ponytail,” shegoes on to say that she knew the colour of the fire officers’ hair because “she wasn’twearing a helmet.”

also states that when she was locking her front door to leave the flatand get out, she heard “screaming” a male screaming, “it sounded like someonescreaming his lungs out.”

The smoke is now about 12 inches from the floor at this stage, and T/LFfhas to crawl when laying/flaking the hose out in the corridor before placing the branchin the end of the hose and then on the floor.

When T/LFf arrives at flat 85after laying out the hose, the door was openbut there was no sign of Ff’s Wornham and Miller, she was very concerned for theirsafety as they did not have water, she does not remember any flames coming from theflat at this stage.

03:05:11 Herts Police Control contacts Herts Fire Control, Control telephone lognumber 26237:

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Fire Operator Hello Police (03:05:12)Police Operator Hello Fire-um I’ve just had a call from Harrow Court in

StevenageFire Operator YesPolice Operator Saying their , their fire alarms are going offFire Operator YesPolice Operator Have you got knowledgeFire Operator Yeah, we know that, we’ve had a report of a flat fire there

which we just booked in attendance at.

Police Operator RightFire Operator We don’t obviously know, don’t know if it is conformed yet,

whether it is a fire or not yet.

Police Operator Right, not yet confirmed, um cause our report came from alady on the 15th floor saying somebody had actuated on the16th floor, but she was, but she was adamant there wasn’t afire, but of course

Fire Operator Right, we had a report that there was a fire, a flat fire, personsreported, um at number 89 Harrow Court, Stevenage.

Police Operator Right, repeats details-fire in flat 89 persons reported?Fire Operator Yes, that’s, we don’t know yet, we just, I just, they’ve just got

there so that’s just what the caller said.

Police Operator OK, will you update us?Fire Operator Yes, what is your reference?Police Operator Our is 100Fire Operator OK, yesPolice Operator And what’s yours?Fire Operator 1693Police Operator Repeats-1693, that’s wonderfulFire Operator OKPolice Operator Thanks very much, byeFire Operator Bye (03:06:30)

03:05:11 LFf re-enters the lobby and while talking on his fire groundhandheld radio, and walks to the lift lobby, after talking to Ff by the dryriser inlet.

03:05:15 Burning debris appears in CCTV camera 11, under the lounge/kitchen of theflat fire, leaving a smoke trail through the air before landing amongst the parked carsbeneath flat 85, however wisps of swirling smoke can be seen on CCTV camera 11 asearly as 03:00:30 but clears within 30 to 40 seconds.

03:05:23 After stowing all the equipment in the lift Ff’s andenter the lift, the door closes and they make their way to the 15th floor.

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List of Equipment taken to upper floor by the second BA crew

2 x 45mm hose2 x hand controlled branch1 x haligan tool1 x First aid kit in bag1 x MARS in bag1 x Thermal Image Camera1 x Service line in line bag1 x BA Entry Control Board (BAECB) and Surcoat3 x Hand held radios (one each)

CCTV shows LFf walking between the lobby and the main entrancetalking/listening to his fire ground handheld radio.

03:05:54 LFf talks to Ff by the dry riser next to the entrance tothe flats.

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03:05:25-03:05:50 Ff dons andstarts up his Breathing Apparatus, andplaces his helmet on his head, Ff

dons and starts his BA set andputs his smoke hood and helmet on.

Ff organises the equipment inthe lift and then places Ff’sand tallies in the electronicsection of the BAECB as it leans

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Fig 5

03:05:57 The left hand lift door opens on the 15th floor, Ff steps out, followedby Ff who is carrying the BAEC board.

Ff states that; he looks around the 15th floor to determine if there was a firesituation on that floor as the air was clear here and the crew were still working to theoriginal address of flat number 89 on the 15th floor.

03:06:00 Ff sorts the remaining equipment in the lift and passes/takes it ontothe upper floor with Ff leaving one length of 45mm hose, (which remains inthe lift) Ff finally exits the lift at 03:07:18.

The following sequence of events is put together using extracts from thestatements made by the other Stevenage crew members, whilst it difficult to pinpoint the exact time of each event, the sequence starts once the 2nd BA crew leavethe lift on the 15th floor.______________________________________________________________________________________________________

Fig 5 Still photo from the CCTV of Ff placing tallies in BAECB, Ff’s and donning their BA

against the lift wall.

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03:07:18 As Ff leaves the lift he tries to contact LFf to determinewhat floor the fire is on but could not make contact as he now believes because hewas on channel 3 and LFf would be on channel 1 he would not have heardanything.

Ff states that there was some confusion here, as he was expecting to see thefirst crew or he thought the fire would be apparent here; he makes his way to the 14thfloor where he notes the corridor and lift lobby was heavily smoke logged with a lightgrey smoke.

T/LFf was back at the dry riser when, Ff’s appeared from the 15thfloor he notices that T/LFf is physically struggling with the dry riser outletand after a brief conversation, immediately went back up to inform Ff’s and

that this was the fire floor.

Ff calls to Ff’s and to come down to the 14th floor from the15th, which they did, passing Ff in the stairwell, he then placed the BAECOboard in the stairwell of the 14th floor.

T/LFf “shouted to” Ff that the first crew had gone in and they hadno water, he immediately ran through the door from the stairwell to the lift lobby, Ff

followed only seconds later.

Ff propelled a naked man, black with soot, from the lift lobby, T/LFfpulled him through the last door into the stairwell area, only seconds later Ff

emerged quickly and ‘threw’ a cat out.

T/LFf and Ff continuing to tried and open the dry riser outlet withthe breaking in tool Ff had brought with him until LFf arrivedwith the bolt croppers at approximately 03:09:02

The position of the dry riser outlet in the stairwell meant that when the hose is laid outit allows the smoke from the flat to spread, from the amount of smoke filling thecorridor and the stairwell, T/LFf knew that the first crew had gone into theflat and were in trouble.

T/LFf told Ff to deal with this person, who subsequently turned outto be Ff states that was on the landing in the 14th floorstairwell, he was shouting and waving his arms he was totally black, coughing, withsinged hair and naked, obviously in great distress.

Ff grabbed hold of as he was concerned for him, and took him tothe 15th floor lift lobby, where the first aid kit and MARS were left, after unloadingthem from the lift earlier.

kept saying, “she’s in there’ she’s in there”, Ff told him he willbe back and left him there to go down to help T/LFf taking the haligan baras he felt he might be able to break the chain with that.

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Ff tried to break the chain off to get water for the hose line, but to no avail,after trying for a while with T/LFf LFf appeared with the boltcroppers and said, “Get out the way”, and cropped the chain.

03:08:06, Ff’s and were “screaming” for “water on” using their handheld fire ground radio’s, contact has been lost with both Ff Wornham and Miller andT/LFf she shouted for the bolt croppers using her hand held fire groundradio on channel one, which LFf responded to at approximately 03:08:06,

T/LFf also stated she believes that it was at this time that she called a BAemergency, although the BA emergency message from appliance 230 was recorded bycontrol as being received at 03:15:59 almost 8 minutes later.

3:06:05-03:06:34 LFf re-enters main lobby area, talks briefly to memberof public, makes his way to the lift lobby, most of this time either listening or talkingon his fireground handheld radio, he then exits the flats.

03:06:31 DO books mobile using the main scheme radio from his car.

03:06:34-03:07:39 LFf walks towards the appliances where he stays in thevicinity with Ff’s and until returning to the flats. This positionoutside, offers clear views of the fire as it was issuing from the windows of flat 85.

03:06:55-03:07:38 Heavy smoke appears in CCTV camera’s 8 and 11, which mayindicate a substantial movement of air in flat 85 such as the front door being opened.

03:07:26 A call to Ambulance Control from Herts Fire Control, Control telephonelog number 26236:

Ambulance Control Hello Fire (03:07:26)Fire Control Hello Ambulance, We’ve taken a call to a flat fire

believed persons reportedAmbulance Control Where are we going to?Fire Control Harrow CourtAmbulance Control Yes

Fire Control That’s SILAM Road, I spell S,I,L,A,M,Ambulance Control Which town is that in?Fire Control Stevenage in HertfordshireAmbulance Control Um, so it’s a house fire?Fire Control It’s a flat fire, believed to be on the 15th floorAmbulance Control OK do you know what flat number or anything?Fire Control Possibly 89Ambulance Control OK pause Are you already there?Fire Control We are there, yesAmbulance Control Do you know how many people are in the flat or

anything?Fire Control We don’t know I’m afraid.Ambulance Control Ok

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Fire Control PauseAmbulance Control Do you have a reference number please fire?Fire Control Yes sure, its 1693Ambulance Control Thank you OK our reference number is 1309809

Both repeat together, 1309809Fire Control That’s lovelyAmbulance Control Sorry, I need to ask are you already there?

Fire Control We are there yesAmbulance Control OKFire Control OKAmbulance Con Yes Thank youFire Control Thank you byeAmbulance Con Bye (03:09:46)

03:07:42-03:08:03 LFf re-enters the flats and makes his way to the liftlobby where is, they appear to have a conversation.

03:08:04 DO books in attendance at Harrow Court using the mainscheme radio; he parks his car towards the rear of the car park, however DOdoes not appear at a position below CCTV camera 8, wearing his PPE, until 03:11:00,almost 3 minutes after his arrival.

DO VI Charlie 2 in attendance overFire Control Charlie 2 your in attendance received VI to standby

03:08:04 DO books in attendance, as Ff sends an assistance messageof ‘make pumps 4’ from 231.

Ff 231 assistance message overFire Control 231 go ahead overFf Charlie 231 make pumps four overFire Control 231 make pumps four received VI to standby

03:08:06 Whilst standing with LFf appears to receive amessage on his fireground handheld radio and responds immediately, he walksthrough the lobby towards the main entrance where Ff is beside the dry riserinlet.

03:08:15 LFf meets Ff picks up the bolt croppers from justoutside the main doors, turns to re-enter the flats, Ff hands LFf asmall yellow bag, (lift keys?), as he walks off towards the lift lobby.

LFf states in his interview that; “he responded to the call for bolt croppersas he was the only person on the ground floor able to take them to the 14th floor as hebelieved everyone else were busy.

Mem Pub 5

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Fig 6

03:08:19 CCTV indicates smoke permeating the right hand lift, the lift door is closedwhen smoke first appears, but the door is seen to open twice before the smoke clears.The smoke seems to pour from above the lift and quickly fills the enclosed lift space,although the lift clears of smoke by 03:09:20.

03:08:20 Products of fire are seen as sparks/debris falling from the fire flat windowsaround the cars on the ground floor car park area.

03:08:24 LFf puts a yellow bag onto the lift floor, he is accompanied byas he takes the left hand lift to the 13th floor with the bolt croppers in his

hand. LFf arrived with the bolt croppers and helped to cut through thepadlocked chain with them, which took two or three attempts to achieve. As soon asthe chain was off LFf turned the dry riser on, immediately charging thelaid out hose, there appeared to be a good “water supply”; he then went down thestairs to the 13th floor.

The following sequence of events is put together using extracts from thestatements made by the other Stevenage crew members, whilst it difficult to pinpoint the exact time of each event, the sequence starts once LFf cutsthe chain and turns the water on.

After LFf had cropped the chain Ff made his way back up to the15th floor to treat the casualty, who had wandered away from where Ff

had left him.

Ff knocked on a flat door and asked for something to cover with;advising the residents to stay where they were, open a window and someone willcome to help you. He was given a duvet, which he took to where was.

Ff wrapped in the duvet, sat him down in the lift lobby andadministered first aid and oxygen using the MARS, reassuring him as he was veryconcerned about his girlfriend and his cat.

Fig 6 LFf with bolt croppers under his arm with Ff at the entrance doors.

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Ff states water came through the hose almost immediately after he had calledfor water over his hand held radio, he followed the hose to where Ff actuallywas, which Ff initially believed, was just beyond the door leading to the fireflat lobby.

Ff was to the left of Ff and appeared to be trying to direct a waterspray on to the fire; Ff then tried the branch on a spray mode but still withoutany effect on the fire, he then tried a jet mode which still did not make any difference,only to increase the heat further.

The heat intensity grew and became very difficult, Ff took control of thebranch and tried to direct a pulse spray onto the fire twice without success, and wasconscious of Ff taking some “punishment” because his helmet was lost andthe heat intensified further due to the steam from the water used.

There was no sound of shouting, screaming or any DSX sounding etc, to indicate thatanyone was in the fire flat at this time although at some stage of the fire Ffdescribes a sound like a “jet engine” or “Bunsen burner” when referring to the firecoming from the flat.

Ff grabbed Ff and retreated backwards pulling Ff behind himleaving the branch roughly where they had been, at some stage Ff ’s BreathingApparatus bypass valve operated giving him a constant flow of air.

Seconds later Ff came flying through the door into the stairwell, with Fffollowing closely behind they were frantic and shouting things but T/LFfcould not understand because of their BA masks, she believes it sounded

like, “we can’t get them” or “we’ve lost them”, or something like that.

Ff s bypass valve was operating giving constant air flow, so T/LFfturned the valve into the off position, Ff was then using his demand valveonly, giving normal breathing control of his BA set.

Ff T/LFf noted, had also lost his fire helmet as he was not wearingit when he came ‘flying’ through the doors with Ff

Ff’s and ran off towards the 13th floor leaving T/LFf alonein the south stairwell of the 14th floor.

The smoke permeating into the stairwell was building to the point that it was loweringand filling the whole area, T/LFf was becoming affected by this smoke andcould not open any windows to ventilate as they had been screwed shut which led toher thinking of “getting out” because there was “no air”.

03:08:48 Ff lays a coiled length of 70mm hose against the main entrancedoor to the flats for easier access and to relieve a resident who had held the doorsopen.

03:08:59 HFRS Control Operator received a Third 999 Call for Harrow Court,Control telephone log number 9493:

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Control Operator Fire & Rescue ServiceCaller Yea, err, I am phoning up, I am in Stoneycroft, that I can see

a fire in Harrow Court, it’s on the forth floor down.Control Operator On the forth floor?Caller Yea its errControl Operator What the forth from the top?Caller Yes, it’s flat 75 I believe, it’s where my brother used to live.Control Operator We are actually in attendance at Harrow Court in Stevenage

now.Caller Oh, right, that’s probably what it is, I just looked out the

window and the place looks like it’s just ‘gone up’.

Control Operator Right, OK, as I said, we are in attendance there now sir.Control Operator But thank you ever so much for phoning in, I really

appreciate it.Caller That’s Ok, that’s OK.Control Operator OKCaller RightControl Operator Thank youCaller RightControl Operator Bye ByeCaller Right, Bye

03:09:06 Burning debris is seen in CCTV camera 4 outside the fire exit door at thebase of the north stairwell.

03:09:11-03:09:41 Ff is at the rear of appliance 230 removing and layingequipment on the ground beside the appliance.

03:09:36 Smoke starts to fill the left hand lift from the ceiling down to the floor fullyengulfing the lift in seconds eventually at 03:10:29 causing the CCTV camera 5 tomalfunction and be un-usable thereafter.

03:09:39 HFRS Control Operator received a Fourth 999 Call, Control telephone lognumber 26238:

Control Operator Fire & Rescue Service (03:09:39)Caller Could I have a Fireman to Harrow Court please? (Audible

fire alarms were sounding in the background)

Control Operator Is that in Silam Road?

Caller Yea, it is yeaControl Operator In Stevenage?Caller It is yeaControl Operator Don’t worry we are in attendance right now, OK, so we are

there,OK.

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Caller Yea

Control Operator Alright, don’t worry

Caller It is alight

Control Operator Yea, we know that, we’re in attendance now, OK.

Caller OK

Control Operator Thank You for your call

Caller OK., bye

Control Operator Bye (03:10:38)

03:09:56-03:10:11 Ff is at the pump bay of appliance 230 before making hisway towards the hose reel locker of appliance 231.

03:10:29-03:10:41 Ff runs out a hose reel to the front of appliance 231 withassistance at the locker from Ff

03:10:44-03:11:20 Ff applies water to the burning debris which is fallingfrom the 14th floor before turning off the hose reel jet and placing the branch on thefloor.

03:11:00 DO had parked his car towards the rear of the car park at 03:08:02;however he does not appear at a position below CCTV camera 8, wearing his PPE,until almost 3 minutes after his arrival at the incident, he then walks towardsappliance 231, LFf is on an upper floor at this time.

03:11:11 Ff climbs into the cab of appliance 231 and stays in the cab untilhe dismounts the appliance and makes his way to the pump bay at 03:12:14

03:11:19 Baldock appliance 310 books mobile and asks for a location for the incident,the details are given and they are made aware that this is a make up of pumps to four.

03:11:23 DO talks to Ff through the window of appliance 231

03:11:35 DO speaks to a Paramedic from an ambulance car.

03:11:38 LFf steps into the right hand lift from an upper floor after havingtaken the bolt croppers to T/LFf and cutting the chains on the 14th floorcharging the hose to the 2nd BA crew, he then left them there.

03:11:43 Ff passes an informative message from LFf (althoughLFf states in his interview he was not aware of this message being sent), toHFRS Fire Control immediately after appliance 310 are given location details:

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Ff (231) Over

Fire ControlOperator

231, go ahead, over


231, understand, persons reported, ambulance required, over

Ff (231) 231 all received, over


231 received VI to standby

03:12:09-03:13:40 LFf meets DO outside the main entrance to theflats, a conversation takes place and LFf hands control of the incident overto DO who now becomes the Incident Commander (IC), LFf alsogives DO the IC surcoat that he was wearing.

LFf states that he brief DO that there was a flat fire on the 14thfloor, four BA wearers in there, was the Forward Control, the dry riser wascharged and the fact that LFf had just made pumps four.

After the arrival of DO LFf states that he was detailed to go backup to the ‘bridgehead’ and take over Forward Command, CCTV camera 3 verifies thathe returned to the upper floors at 03:16:36, as he is seen entering the lifts.

03:12:31 HFRS Fire Control contacted the Ambulance Service to confirm that theincident was persons reported and to find out the ETA of the first Ambulance to thescene:

03:12:31 HFRS call to the Ambulance Service, Control telephone log number 26240:Ambulance ControlService

Hello, Ambulance Service (03:12:31)

Fire Control operator Hello Ambulance Service, your reference 1309809, thisis to confirm persons reported, can you give ma an ideaof your ETA please?

Ambulance ControlService

Yes, one vehicle which is just over a mile away andwe’ve got one vehicle just arrived on scene

Fire Control operator You’ve actually got one on scene

Ambulance ControlService

We’ve got an emergency car just arrived on scene

Fire Control operator Right, okay okayAmbulance ControlService

OK, so it’s definitely pers. Peoples reported?

Fire Control operator It’s confirmed persons reported, yesAmbulance ControlService

Confirmed, OK I’ll pass that on to my manager

Fire Control operator OKAmbulance ControlService

OK, Thanks, Bye Bye

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03:12:56 Ff walks towards pump 230, Ff runs towards the roadway(Silam Road), passing CCTV camera 7 at 03:13:10, he re-appears at CCTV camera 7running towards appliance 230 at 03:13:51.

03:13:00-03:13:14 Hitchin’s appliance 320 books mobile to Harrow Court withLeading Firefighter as Officer in Charge

03:13:31 320 appliance were contacted by Fire Control to give location details and toinform them that the incident is make pumps four with persons reported.

03:13:42 LFf re-enters the flat lobby and walks towards the lifts, he looksat both lifts then walks back outside and towards DO

03:14:07 999 call number 01699 was received in Fire Control from a resident ofHarrow Court.

03:14:09 LFf catches up with DO as he walks in the direction ofhis car and a brief conversation takes place.

03:14:30 Ff walks past CCTV camera 7 carrying hydrant equipment makinghis way back to Silam road.

03:14:56 DO and LFf walk toward appliance 230 where they aremet by Ff near the front nearside cab area.

03:15:02 DO then turns and walks on towards the rear of the car park stillcarrying the Incident Commander surcoat.

LFf walks towards the flats turns takes a couple of paces towards whereDO is walking then resumes his original direction towards the flats, Ff

enters the Officer in Charge seat of appliance 230.

T/LFf who is not wearing a fire helmet, appears in CCTV camera 4 at thebase of the stairs in the north stairwell, exits by the fire exit door, where burningdebris can be seen falling from the main bedroom above, before making her wayaround the building passing under the ‘fire flat’.

03:15:20 T/LFf and LFf meet by the dry riser hoses, beforewalking into the flats and making their way to the lift lobby, both appear to belistening to their fireground handheld radio’s.

03:15:47 DO meets LFf and T/LFf in the lift lobbywhere he has a conversation with T/LFf while LFf exits the flatsbefore walking towards appliance 231.

Ff steps down from the cab of appliance 230 and speaks to Ff whohas just returned from the roadway.

Fire Control operator Bye Bye (03:13:28)

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03:15:59 Ff recalls, T/LFf calling a “BA Emergency” over andover on channel one of his fire ground handheld radio, when he was around the backof 231 at the pump bay, he ran to appliance 230, climbed in, and sent the BAemergency message over the main scheme radio to HF&RS Fire Control whoacknowledged that the message had been received.

Ff (230) 230, overFire Control Operator 230 go ahead, overFf (230) 230, BA emergency, overFire Control Operator Understand BA emergency, overFf (230) 230 all correct, overFire Control Operator 230 received VI to standby.

03:15:53-03:16:07 LFf exits the flats before walking to appliance 230 andconfirming with Ff that the BA emergency message had been sent.

Ff walks towards Silam road carrying further items of hydrant equipmentpassing an ambulance entering and moving towards the Harrow Court car park area.

03:16:13-03:16:49 DO T/LFf and LFf are in thedoorway leading into the flats, until LFf walks towards the lifts, howeverthe others remain there and continue their conversation.

03:16:28-03:16:39 LFf re-enters the flats walking towards the lifts wherehe looks at the left lift before the door opens on the right lift which he enters.

03:16:28-03:17:47 Ff reappears in CCTV camera 7 from the direction ofSilam Road running out a length of hose, before walking to the rear of appliance 230and taking more hose to run out for the hydrant length, assisted by Ff

03:16:43 999 call number 01701 was received at Fire Control from a resident on the13th floor of Harrow Court who was concerned about the fire and debris falling passedhis windows.

03:16:49-03:17:54 T/LFf can be seen on CCTV camera’s 2 and 3 movingbetween the main lobby area and the lift lobby area talking to the police andoccasionally listening to her fireground handheld radio.

03:17:06 DO dons the incident Commander surcoat beside appliance 230.

03:17:14 LFf exits the right hand lift into the 13th floor lift lobby, hepasses a resident who enters the lift, going to the ground floor.

The following sequence of events is put together using extracts from LFfFf and Ff ’s statements, whilst it difficult to pin point

the exact time of each event, it outlines their actions once they had gone up thenorth staircase to the 14th floor landing where they found Ff Wornham atapproximately 03:18:30.

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Ff ran into the stairwell he found the fire door closed to the lobby outside thefire flat, the fire was on the opposite side and glowing bright.

He ran up the stairs pushed open the door, his smoke hood was not pulled intoposition properly and the heat was very intense, he immediately felt the heat on theside of his face.

He saw Ff Wornham lying there on his back with his feet towards the landing doorand his head towards the front door of flat 85, although he did not know who it was atthat stage; he tried to move him by pulling on his legs but could not move him at all.

Ff and Ff tried to pull Ff Wornham free but without success, at first itappeared he was stuck to the floor although on further examination it became clearthat Ff Wornham was tangled up in some cables. They managed to move FfWornham’s foot which was now in the door way, stopping the fire door from closing.

They decided to get water and ran down to the 13th floor to get a line of hose from thedry riser as he did not want to take the first length run out onto the 14th floor as it was‘their’ lifeline, meaning Ff Wornham and Ff Miller.

LFf believes he was making his way back to the lifts on the 13th floor,when Ff came ‘flying’ and crashing through the door into the south stairwellin some degree of distress still wearing his breathing Apparatus.

When Ff arrives at the dry riser on the 13th floor, he shouts that he needs thebolt croppers and runs up to the 14th floor to get them. Ff has already run outthe hose to the south stairwell leaving the coupling at the dry riser for FfLFf tells Ff to hand the bolt croppers over, and he cuts through thechain of the dry riser outlet on floor thirteen and Ff turns on the water for Ff

who is at the branch end of the hose.

The following is taken from the mobile phone message to control from DOindicting Ff calling for water at the branch in the stairwell of the north stairs.

Fire Control Fire & rescue Service. (03:20:13)

It’s hang on a sec, I’ve just got them talking onthe radio, hang on a sec.

From the radio “Priority water on”, “water on”, following a pause “water on“said very loudly.

From the radio “Hold fire, , hold fire”. (sounds like the voice of LFf

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Ff runs back to the north stairwell, the water is following him along thecorridor, he helps Ff to get the hose to the door but is restricted by the lengthwhich would not allow access into the lobby, they could only try to get water to thefire from the stair landing.

Ff tried to move Ff Wornham but again without success,

Ff s low pressure warning whistle started to operate but he carried on trying toget water to the lobby with Ff and to rescue Ff Wornham until he “ran out ofair” and his mask was “sucking” onto his face.

LFf remembers, “Ff ’s BA low pressure warning whistle operatingat some stage while he was on the upper floor with him and Ff but he doesrecall exactly when”.

03:17:45 Ff makes his way to Silam road following the 70mm hose he and Ffhad lain out.

03:17:54 DO states in his interview that he had asked T/LFf to goback up to “support the BA” in a forward sector which is appropriate to an incidentlike this.

DO enters the main lobby and looks towards the lift lobby as T/LFfenters the right hand lift.

03:18:19 Supervisory Officer DO was informed of a BA Emergency at anincident in a high rise building at Harrow Court, Silam road, Stevenage, although hewas not requested to attend at this time.

T/LFf enters the right hand lift with a paramedic passing the resident as heexits the lift into the ground floor lift lobby, she is not carrying any equipment otherthan her fire ground handheld radio attached to her tunic clasp, she exits the lift on anupper floor.

Fig 7

Fig 7 T/LFf in the right hand lift with a paramedic proceeding to the 13th floor.

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03:18:26 T/LFf exits the lift on the upper floor.

03:19:00 Footage from CCTV cameras 7 and 8 show the single hydrant lengthrunning from the roadway to the appliances being charged with water.

03:19:31-03:19:44 The lift doors open in the upper floor lift lobby showing twopersons are outside the lift, was this T/LFf with the paramedic?

03:19:47 Hitchin’s second appliance, 321 books mobile to Harrow Court with SubOfficer as Officer in Charge.

03:20:04 DO was notified of the incident by telephone, as part of the BAEmergency procedure?

03:20:13 DO uses his Fire Service mobile phone to send an assistance andinformative message. Whilst he was sending this message a number of exchangeswere heard on his fireground handheld radio in the background.

The following is transcript of the call and what can be heard in the background:

Fire Control Fire & rescue Service. (03:20:13)

It’s , hang on a sec, I’ve just got them talking onthe radio, hang on a sec.

From the radio “Priority water on”, “water on”, following a pause “water on“said very loudly.

From the radio “Hold fire, , hold fire”. (sounds like the voice of LFf

DO go ahead over, as he tries to contact the persons onthe radio.Background music is then heard playing on DOtelephone.LFf go ahead, over, as he uses his firegroundhandheld radio.There is a period of just music until a beep sound is heard andthe music stops.

Fire Control Hello, sorry.

Hello, OK,Make pumps 4 and get me, make officers 8 and we have abuilding, its an informative message, a building, I think on the14th floor, whatever you have been told previously.Obviously it’s a block of flats and we have possible personsreported.BA presently, 1 jet I believe in use at the moment.Tactical mode, very Oscar.

Fire Control Right, OK, just to confirm that sir:make pumps 84 Officers

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4 BA in usejet in useTactical mode Oscar.Absolutely.

Fire Control OK sir that’s fine, that’s done for you.Thank You, Bye.

Fire Control Thank You, Bye Bye. (03:21:45)

03:20:20-03:20:35 Two Ambulance personnel enter the main foyer and after a briefdiscussion one mounts the stairs to the upper floors passing T/LFf

03:20:33 The third and fourth fire appliances 310 followed by 320 book ‘inattendance’ at the incident, and were immediately instructed to send two BA crews togo up to the 14th floor., this was approximately 16 minutes after the first 2 appliances,more than 4 minutes after the initial Breathing Apparatus Emergency was declared.

03:20:35 T/LFf appears at the base of the south stairs and makes her wayout of the building using the main entrance doors.03:20:42 Appliance 320 deploys in front of, and facing appliance 230.

DO is in the car park near the front entrance to the flats until 03:20:48 whenappliance 320 arrives and he makes his way over to where it has deployed.

Fig 8

03:20:48-03:21:37 Appliance 310 deploys at the bottom of the main entrancedriveway.

T/LFf makes her way towards the Fire Personnel who are dismounting fromthe two appliances and meets them at the front of appliance 320.

DO walks from the car park area towards the group.

A briefing takes place at this point.

03:21:10 The right hand lift door opens showing water beginning to pour from theceiling area, this torrent increases very quickly, flooding the lift floor.

Fig 8 DO making his way towards 320 as they arrive at Harrow Court.

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03:21:47 T/LFf enters the main foyer with Sub Officer and twoBA wearers, she points towards the stairs and then the lifts, the Firefighters in thefoyer are joined by two other wearers, all five make their way to the lifts, while T/LFf

turns and walks towards the main doors and exits the flats.

03:21:58 DO radio call sign Charlie one, was requested, as the next nearestOfficer, to attend this incident when the make pumps 8 and officers 4, message wasreceived by Fire Control.

03:22:07 A Paramedic enters the flats and walks up the stairs to the upper floors.

03:22:19 Sub O enters the left hand lift with the four BreathingApparatus wearers, Ff’s and from the Baldockand Hitchin appliances all proceed to the 13th floor, and then walked up to the firefloor.

Fig 9

On the way up to the 14th floor they past FF on his way down, when theyarrived on the 14th floor, they relieved FF who was still trying to release FFWornham.

Ff says that he went down the stairs yanking the mask off his face, where hepassed the BA team from Baldock’s appliance and told them, “he’s up there, he’s upthere” he then started to make his way along the corridor where he passed a womanwho asked if he was alright he replied that she must go that way.

The following sequence of events is put together using extracts from thetranscripts made of the statements made by Ff and Ff the3rd BA crew, whilst it difficult to pin point the exact time of each event, itsummarises their actions once they had relieved Ff’s and Ff

Fig 9 Still photo copied from CCTV footage of Sub Officer & the 4 BA wearers in lift lobby before entering the lift.

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FF Wornham was found in the lobby area outside flat 85, on his back with his feettowards the landing door and his head towards the front door of flat 85, at first itappeared he was stuck to the floor although on further examination it became clearthat FF Wornham was tangled up in some cables.

FF from the 3rd BA crew, stated that: “I couldn’t lift him off the floor no.”“Cables had come down in this lobby area here,” and there was probably four andthey were between his BA set and his back, “ yeah so they’d dropped down behind hishead over and then wedged or got stuck between his set.”

FF from the 3rd BA crew, states that:“ But we pulled him up off the floorit was almost like err he was stuck to the floor.” “Yeah, he’d almost snagged like apuppet and they were coming down from the ceiling.”

The cables were, all round his set we were trying to untangle them, it was like acrosshis front as well but only a couple across his front it was mainly all behind him.Initially I thought they were just tangled up in his set but it was they were melted onto his set and his tunic as well.

“ was the other side and we were working behind him to try and get the wiresuntangled from around his set.” I was aware that there were two other people tryingto untangle him, which were the two Hitchin boys.

“ got his knife out and I was like holding the wires like together so he could cutthrough them” and then once he was released a bit, apparently they’d used an axe aswell but I didn’t see that.

03:22:24 Police Control inform Fire Control that they have received a call from aresident on the 14th floor, flat number 81, who believed he was trapped and isconcerned that he had not been evacuated as it appeared that others had. Fire Controladvised Police Control to pass on to the resident to remain where they are until theFire Service decides to evacuate.

03:22:48 Ff and who is wrapped in the duvet, appear at the baseof the south stairs, Ff passes LFf as he escorts from thebuilding to the paved area outside by the car park, as LFf mounts the stairsand makes his way to the 13th floor to become the Breathing Apparatus Entry ControlOfficer.

03:23:00 Ff walks outside and treats him for two minutes on thepavement by the car park, before he helps him to the rear cab of appliance 230 withthe aid of Ff at 03:24:42.4

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Fig 10

03:23:03 DO uses his mobile phone to send an informative message. Whilsthe was sending this message a number of exchanges can be heard in the backgroundon his fireground handheld radio.

The following is a transcript of this call:

Fire Control Controlagain, at the incident. Just to let you know that we

still haven’t confirmed all persons accounted for as yet.

Fire Control RightAnd we’ve lost contact with one BA team.

Fire Control Right, add that to the informative, all persons not yet accountedfor.

Repeats, all persons not yet accounted for and we are…? OKFire Control Yes, we are getting lots of calls from people on other floors

here to say they think they are trapped.

OKFire Control We are telling them to stay in

Tell them to stay in their flats for the time being, yes.The fire is contained to the floor at the moment

Fire Control RightHowever we need to get some water on it a bit quick, otherwiseit might ‘nip up’. I think at the moment we’re probably OK.

OKFire Control Thanks

Alright then.Fire Control Cheers

CheersFire Control Bye

Fig 10 Still photo copied from CCTV footage of Ff escorting out of the building.

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03:23:18 Two fire personnel enter the flats and proceed up the stairs to the upperfloors carrying items of equipment.

03:24:42 Ff and Ff escort to the back of appliance 230 tomake him more comfortable, he remains in the rear of the appliance with Ffwho received help from ambulance personnel, until taken by stretcher to anambulance at 03:57:14.

03:24:48 A Firefighter walks into the flats, mounts the stairs and makes their way tothe upper floors.

3:26:06 Ff appears at the base of the south stairs with Ff both lookingshocked and covered in products of fire, they cross the entrance foyer and exit theflats by the main doors.

03:26:09 DO sends an assistance message using his mobile phone requesting 4Ambulances, there are many background transmissions from around the fire groundand also from Firefighters near him, heard during this request, logged as call number26250.

The Herts and Beds Ambulance were contacted by Herts fire Control requesting the 4Ambulances and were informed that there were already 3 in attendance with twoAmbulance officers, logged as call number 26253 recorded at 03:27:50.

Fig 11

03:26:15 LFf following closely behind Ff‘s and appears atthe base of the south stairs before walking across the foyer and out the main door.

03:28:00 A further two firefighters wearing BA, enter the flats and make their way tothe left hand lift and make their way to the upper floors.

03:28:15 Hitchin second appliance call sign 321 booked in attendance; radio call lognumber 2799834.

Fig 11 Ff’s & appear at the base of the south stairs.

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03:30:48 DO uses his mobile phone to send a further informative message.

Fire Control ControlHello its

Fire Control Hello sirFurther informative 8 BA as per previous,

Fire Control Yeh8 BA,

Fire Control YehJets,

Fire Control Yehstill 2 persons—2 BA un-accounted for,

Fire Control You’ve got 2 persons or 2 BA.Sorry 1 BA team un accounted for

Fire Control Right 2 jets, so still one BA team un accounted for,And 1 person un accounted.

Fire Control Yeh YehTactical mode Oscar

Fire Control OK SirFire Control Any more actions you want us to carry out, or is it alright.

UM,……..You can have, you can have a look through theService Order on High Rises, make sure we have everything weneed for that for me and give me a ring

Fire Control OK Sir will doArh, At the moment we don’t need an aerial platform oranything.

Fire Control No ALP required at this timeNO

Fire Control OK Sir thank youBye

Fire Control Cheers Bye Bye

03:32:49 Another team of four BA wearers enter the main foyer, mount the stairs andmake their way to the upper floors.

03:35:05 DO and Sub Officer enter the flats, after inspecting thelifts meet a Leading Firefighter as he arrives at the base of the stairs from the upper

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floors, and following a brief conversation, they then make their way to the upper floorusing the stairs.

03:36:33 DO sends an additional informative message using his mobile phonestating; addition to previous informative, fire has now spread to the 15th floor inaddition to the 14th floor, all other details the same, tactical mode Oscar, logged as callnumber 26263.

03:38:55 DO call sign H18, books in attendance just seconds after call sign190, the first appliance from Welwyn Garden City booked in to Harrow Court.

03:39:10 Two Firefighters who are not wearing BA enter the flats and make their wayto the upper floors using the stairs.

03:40:00-03:41:36 Two ambulance personnel enter the main foyer with a stretcherfollowed by a police officer, T/LFf Ff’s andFf has a conversation with the Ambulance team, pointing towards the lifts hashe does, they then make their way towards the lifts as DO arrives in the foyer.

DO had discussions with T/LFf Ff and Ff with thepolice officer looking on.

Following the discussions Do turns and meets a Firefighter in the doorway,after discussions both leave and make their way outside; T/LFf exits theflats listening to her radio.

Ff enters the open left hand lift and removes the lift key bag and a length of45mm hose, to allow access to the Ambulance team with the stretcher, who then maketheir way to the upper floors, while two BA wearers make their way to the upperfloors using the stairs.

03:41:36 Ff’s and wait in the lift lobby and are then joined by T/LFfwho is carrying a yellow bag of lift keys, at 03:42:16 a key is used to

attempt to take over the right hand lift, although this is unsuccessful at this time.

DO call sign H6, books in attendance just seconds after call sign 311, thesecond appliance from Baldock booked in to Harrow Court.

03:42:40-03:44:06 A team of five Fire Service personnel enter the flats carrying a firstaid kit, a MARS and a BAEC board and had a brief discussion with T/LFfFf’s and

The following sequence of events is put together from the transcripts made of thestatements made by Ff and Ff the 4th BA crew, is précis of whatthey saw, and their actions ending when they are seen leaving the building at03:43:44.

The two BA wearers from Baldock were up the stairs and Ff was behind Ffat the top of the stairs to the 14th floor trying to sort out the jet that was laid

out.

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Ff was at the front with Ff behind him and Ff next inline with Ff at the back, the three BA wearers at the front managed to move thecasualty to a sitting position in the doorway where Ff saw that he was tangledand twisted up with cables and things that had fallen down and melted and twistedaround him. Ff states that Ff Wornham was in full PPE with his BA set andmask still in place.

Ff took his glove off to get his knife from his inner pocket of his tunicimmediately feeling the intense heat on his exposed skin, he opened his knife to cutthe wires and realised that Ff was doing the same thing with his knife.

Ff saw Ff take his knife out and between them cut some of the wiresand moved the casualty a short way to the top of the stairwell by the door, as this washappening he felt the effects of the heat on his cheek through his smoke hood and hada small burn on the right of his face afterwards.After the wires were cut the BA crews carried the casualty down the north stairs andhanded him over to LFf who told Ff to be careful because he hadslipped on the stairs where there was water gushing down.

The BA crews from Hitchin and Baldock worked together and tried to advance withthe jet, but it was too short, a further length of 45mm hose was flaked out and wasthen used to extend the branch.

The crews advanced into the flat, crawling to keep low because of the intense heat, Ffstates that it was soaking wet on the floor because of the water, Ff’s

and were at the branch and were knocking down the fire as they movedforward.

Ff’s and went into the first bedroom to carry out a search, as theyentered Ff saw a casualty not far from the entrance, in the corner, hedescribes the scene, “everything was burnt down to a very low level and it looked justlike a bonfire which had almost burnt out”, and “obviously it was very smoke loggedto a low level”.

As they proceeded into the room FF realised that there was a casualty andfrom the indications around him he believed it could be a Firefighter as he couldrecognise a BA cylinder with what looked like some of the yellow plastic cover intact,although the BA cylinder was not close to either casualty.

After looking closer Ff realised that anyone that was in that room during thefire was beyond help, and there was nothing they could do for them, he rememberscoming out of the bedroom and passing the information to Ff

The BA crews continued to extinguish the fire and search as they advanced, whenthey reached the kitchen they realised they were ‘low on air’ and needed to get out, asthey exited the flat Ff saw a fire helmet in the lobby area.

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All the BA wearers made there way to the 13th floor where they met Sub Officerwho asked them if they had found Ff Miller, Ff was unaware that

they had so Ff told Sub Officer that he was in the first bedroom, butthat he was beyond help and they had left him in situ.

Sub Officer wanted confirmation of the casualty, so detailed another BAcrew to go in and report back to him, Ff briefed the next BA crew as to whereto go and where to find Ff Miller, the first BA crews collected their tallies from theBAECO, and they then make their way down the stairs.

03:43:44, CCTV footage from camera 2 shows four BA wearers, with PPE coveredwith products of fire, appear at the base of the south stairs from the upper floors looktowards the lift lobby, and talk to T/LFf before making their way out of themain door with T/LFf

03:45:04 A Firefighter enters the flats talks to Ff’s and who points upthe stairs, as the Firefighter makes his way to the upper floors.

03:45:36-03:46:00 Four Fire Service personnel appear from the upper floors at thebase of the stairs and run to the lift lobby, where they meet Ff’s andthey shield them as the left hand lift door opens.

03:46:02-03:46:39 The left hand lift door opens and two Fire Service personnel andthe two ambulance personnel push out the stretcher carrying Ff Wornham, who isunder oxygen, into the lift lobby before taking the stretcher outside with support fromothers.

03:46:39-03:47:06 The stretcher was manoeuvred across the fire ground past theappliances before being taken to an awaiting ambulance parked on Silam Road. Ff’s

and are consoled and helped by a Leading Firefighter in the lift lobbyarea

03:49:47 The mobile Fire Control Unit, call sign 189 from Hatfield, books inattendance just seconds after call sign 191, the second appliance from WelwynGarden City booked in to Harrow Court.

03:50:08 DO sends a further informative and assistance message using hismobile phone stating that one Firefighter had been found, believed code one, had beenleft in the flat, and he wants to make pumps 10 and Officers 6. There are manybackground transmissions from around the fire ground during this call, logged as callnumber 26270.

03:55:49 ACO call sign H3, was informed on his mobile phone that therewas a Firefighter code one and that an informative message had asked for 10 pumpsand 6 Officers.

04:05:02-04:07:37 Although there was lots of activity as many appliances and FireService personnel arrived at this incident, the next significant event relating to LFf

as relayed in his statement, is when he takes some breaking in equipmentto the upper floor to allow ventilation to reduce the smoke in the north stairwell.

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04:18:28 T/LFf with another service person, appears at the base of the stairsfrom the upper floors, she is carrying a fire helmet, they make their way out of theflats.

04:28:21 ADO call sign C6 contacts Fire Control from Lister Hospital wherehe is in attendance, to confirm that the Firefighter taken by the Herts and BedsAmbulance from Harrow Court “was Firefighter Wornham and that” he had beendeclared code one.

04:49:38 A further informative message sent to Herts Fire Control by Firefighterin the Incident Control Unit from ACO gave the following

details:

One Firefighter believed code oneTwo civilians believed code oneAll casualties left in situOne Firefighter taken to hospital14th floor has been searchedFire is all outDamping down in progressA search is being carried out of the 15th floor10 BA in useTactical mode OscarAn addition was added to the message during the phone message:BA main control is being set up

06:00:02 An update informative message sent to Herts Fire Control by Firefighterin the Incident Control Unit from ACO gave the following

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Fire is all outDamping down in progressBA in useBA main control no longer requiredFirefighters and 1 civilian confirmed as code onefurther Firefighter is receiving treatment for burns in hospitalApproximately 70 persons led to safety to local community centreApproximately 10 casualties referred to hospital by self referralAll persons accounted forTactical made Oscar

07:06:35 The stop message was sent from the Mobile Control Unit call sign 189 withthe following details:

Stop from the control unit 189, Papa 03 86 95, 3 persons code one, 7 persons codetwo and seventy persons code four.

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3 Executive Summary

The following is a summary of the Health & Safety investigation conducted by theFire Brigades Union (FBU) into the tragic fatalities of Firefighter Wornham andFirefighter Miller who lost their lives at 85 Harrow Court, Silam Road, Stevenage,Hertfordshire on 2nd February 2005. The investigation identified areas oforganisational weakness that the FBU believes significantly contributed to the risksfaced by Ff Wornham and Ff Miller – risks that ultimately took their lives.

There has been, and shall continue to be, much debate and speculation as to the exactscientific nature of the fire phenomena that occurred at the Harrow Court incident.Experts shall continue to muse over the distinguishing features of a flashover, abackdraught, a smoke explosion, a blow torch effect, wind assisted rapid developmentand other extreme fire phenomena. As with all scientific theories, they all remainvalid until such time as they may be disproved and so it is difficult to establish in thiscase which type of fire phenomenon caused the deaths.

However, there is one important area of agreement in the case of the Harrow Courtincident between the various scientific theories: It was the opening of the front door toFlat 85 that gave rise to the rapid manifestation of whichever fire phenomenon thatdid then occur.

Given this common area of agreement, it can be concluded that had Ff Wornham andFf Miller not opened the front door at the exact time that they did, then the firephenomenon is unlikely to have occurred at the time that it did and the twoFirefighters would not have been exposed to its fatal effects. This being the case, theFBU believes that establishing the cause of their deaths has less to do with the precisedefinition of the fire phenomenon that occurred and more to do with those factors thatled to Ff Wornham and Ff Miller opening the front door when they did and withoutthe necessary water, resources or personnel they required.

Distressing as it is, particularly for the friends and family members involved, attentionshould be drawn to the evidence that Ff Miller appears to have been killed instantlyinside the bedroom of Flat 85, whilst Ff Wornham was found on the floor of the lobbyimmediately outside the flat, entangled in the electrical cabling that had fallen as aresult of the plastic cable-trunking having melted. Moreover, specific attention shouldbe drawn to the evidence that Ff Wornham was found entangled in the electricalcabling, with melted plastic fire alarm cable-insulation adhered to the inside palm ofhis glove, rather than being found with the electrical cabling simply lying on top ofhim. The FBU believes this evidence indicates that, unlike Ff Miller, Ff Wornhamwas somehow able to make his own way out of Flat 85, or was already outside Flat85, before becoming entangled in the electrical cabling that had fallen in the lobbyoutside. In either circumstance, the FBU concludes that it was outside Flat 85, trappedamongst the cabling, that Ff Wornham lost his life.

These pieces of evidence reinforce the FBU’s view that the reasons for the absence ofwater, other resources and sufficient personnel must be examined in order to establishthe extent to which those factors contributed to the causes of death.

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Moreover, it is only by examining those factors that the tragic deaths of Ff Miller andFf Wornham might be used to prevent a similar tragedy occurring again.

The FBU report makes 73 recommendations which had they been identified and fullyacted upon prior to the incident, the FBU believes would have significantly reducedthe risks faced by the two Firefighters and may have effectively saved their lives.Sadly, it is too late for Ff Wornham and Ff Miller, but, the FBU believes that properlyacting upon the recommendations in this report now would significantly improve theHealth & Safety of all Firefighters when they inevitably encounter similar incidenttypes as that attended by the Hertfordshire Firefighters in the small hours of themorning at Harrow Court on 2nd February 2005.

This comprehensive report is divided into specific sections and sub-sections but theareas of organisational weakness can be summarised as falling into 3 main categories:Standard Operating Procedures (SOPs), Training and Emergency ResponseResources.

Standard Operating Procedures

The investigation identified many organisational weaknesses in the development,monitoring and review of Standard Operating Procedures. In particular, the High RiseIncident Procedures were wholly inadequate and failed to take account ofrecommendations following the HSE Improvement Notice awarded to the StrathclydeFire Board; the Breathing Apparatus Procedures failed to satisfy the provisions ofnational guidance issued by Her Majesty’s Inspectorate; and the Incident CommandProcedures were inadequate and omitted many provisions contained in the nationalguidance issued by Her Majesty’s Inspectorate.

The FBU considers these Standard Operating Procedures produced by HertfordshireFire & Rescue Service (HFRS) were inadequately drafted, monitored and reviewedand as a result, were not fit for purpose at the time of the Harrow Court Incident.

Training

The investigation identified serious inadequacies in the provision of training for theHertfordshire Firefighters that attended the Harrow Court incident. The circumstancesand events of the Harrow Court Incident on 2nd February 2005 exposed widerconcerns of the apparent under-provision of training in HFRS.

Between them, it is apparent that the Firefighters and supervisory officers in the initialattendance at Harrow Court had received insufficient formal Incident Commandtraining, Crew Command training, Dynamic Risk Assessment training, BreathingApparatus (heat and smoke) Refresher training and separately dedicated, practical andtheoretical Compartment Fire Behaviour training to deal safely and effectively withthe situation they were confronted with. Specifically, the FBU notes the lack ofpractical attack training for compartmental fires.

In addition, it is clear that any basic awareness of High Rise Incident procedures wasnot sufficiently underpinned with practical High Rise Incident training at either theTraining & Development Centre or at fire stations.

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The Firefighters were unfamiliar with the premises and the likely risk they wouldencounter in an emergency, as they no longer carried out 1(i)(d) inspections on thesetypes of premises.

The deficiencies in training exposed by the Harrow Court incident seem to betray anapparent and endemic organisational weakness in the provision of training in manyother operational areas of firefighting. Predominantly, this seems due to a lack ofstrategic emphasis, planning, monitoring and review by senior managers of actualtraining undertaken and insufficient resource allocation.

The recommendations on training in this report primarily seek to develop sufficienttraining to underpin the recommended revisions of HFRS Breathing Apparatusprocedures, High Rise Incident procedures and Incident Command procedures.Thereafter, it is clear that improved systems, increased resources and allocatedtraining time are required both at fire stations and at the Training & DevelopmentCentre to enable the effective delivery of a wide range of safety critical training for allfirefighting personnel and supervisory officers. The resource increases necessarilyinclude the need for additional instructors to deliver, monitor and review training andthe maintenance of sufficient staffing levels at fire stations to afford firefightingpersonnel the amount of dedicated training time their safety deserves.

Emergency Response Resources

To determine the appropriate resources to be deployed in response to an emergency itis necessary to assess the actual risks that exist in the area, the emergency scenariosthat might occur and the Standard Operating Procedures to be systematically deployedto deal safely and effectively with those emergency scenarios. The Fire Services Act2004 and guidance issued by the Office of the Deputy Prime Minister (ODPM)require HFRS to plan for, and provide, the required weight and speed of emergencyresponse resources to actual risks that exist in HFRS territory.

However, the FBU Investigation identified serious organisational weaknesses in theidentification, assessment and inspection of actual High Rise risks; seriousorganisational weaknesses in the systematic assessment, monitoring and review ofstandard operating procedures to respond to compartment fires within actual HighRise risks; and insufficient provision of emergency response resources to form theinitial attendance for compartment fires in High Rise risks such as Harrow Court.

The 3 main categories above attempt to summarise the wide-ranging findings of thereport. The full list of recommendations can be found in Section 14. Broadly, theserecommendations seek to achieve:

The proper identification, assessment and regular inspection of High Rise premisessuch as Harrow Court;

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The comprehensive review of Breathing Apparatus procedures & training,Compartment Fire Behaviour procedures & training, High Rise Incident procedures &training and Incident Command procedures & training in the light of this report, otherrecent fatal incident reports, relevant HSE Improvement Notices, Fire ServiceManuals and other relevant technical research, information and Fire Service Circulars;

The review of the HFRS Integrated Risk Management Plan such that the initialattendance of emergency response resources for High Rise Incidents ensures aminimum of 13 Firefighters arrive in sufficient time of each other to enable all of theservice’s safe systems of work to be implemented in full at the outset and withoutendangering Firefighters due to a delay in their arrival.

Under the direction of the Minister, The Review of Standards of Emergency CoverReport – Technical Paper C – Response & Resource Requirements came to theconclusion that:

“It is essential to avoid situations which could motivate or pressurise Firefighters toact unsafely in the interests of saving life”.

At High Rise Incidents the recognised means of achieving this is through establishinga “Bridgehead” as the platform from which to launch rescue and firefightingoperations in accordance with appropriate standard operating procedures forBreathing Apparatus, Compartment Firefighting and Incident Command. The FBUfirmly believes that HFRS failed to ensure their standard operating procedures (SOPs)were fit for purpose; failed to ensure the application of the SOPs were systematicallyand practically trained for; and failed to ensure that sufficient personnel weremobilised for deployment on the initial pre-determined attendance (PDA) to allow theimmediate, safe and effective implementation of the applicable SOPs.

The FBU applauds the courage shown by all the HFRS firefighting crews thatattended the Harrow Court incident in the small hours of 5th February 2005. Inparticular, the selfless and courageous actions of Ff Wornham and Ff Miller wereimmense given the circumstances they found themselves in.

The key questions are:

Would the fatalities of Ff Wornham and Ff Miller have been prevented had HFRSensured adequate procedures, training and resources were systematically in place?

Almost certainly!

Would the life-threatening risks faced by the Firefighters at the Harrow Courtincident have been significantly reduced had HFRS ensured adequate procedures,training and resources were systematically in place?

Without doubt!

As a conclusion to our Health and Safety Investigation, the FBU believes that theconduct of Hertfordshire Fire & Rescue Service significantly contributed to the deathsof Ff Wornham and Ff Miller in that they failed to comply satisfactorily with the Fire

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Services Act 2004; the Health and Safety at Work Act 1974; the Management ofHealth and Safety at Work Regulations 1999; national guidance issued by HerMajesty’s Inspectorate; and failed to act adequately upon relevant Health and SafetyExecutive (HSE) improvement notice recommendations available to them. Similarly,during the course of the FBU’s Health and Safety Investigation HFRS failed tocomply with the Safety Representative and Safety Committee Regulations 1977.

It is not known whether the smoke alarm in Flat 85 activated or not. However, nobodyreported hearing the smoke alarm in Flat 85 sounding at any time. Since it may nothave activated and had it done so the occupants may have made their own way tosafety, the FBU’s Health & Safety Investigation concludes that Stevenage BoroughCouncil (SBC) may have contributed to the deaths of Ff Miller and FF Wornham inthat they failed to undertake a review of the smoke alarm installations in theindividual flats at Harrow Court to assess their appropriateness as recommended inBS 5839-6:2004 annex A 4.1 a & b and 5.1 a, b & c.

Similarly, until such time as the relevant Fire Safety Completion Certificate is madeavailable or it is confirmed that the installation of the new fire detection and alarmsystem to the common areas at Harrow Court complied with the latest Buildingregulations and the appropriate British Standard, the FBU’s Health and SafetyInvestigation also concludes that SBC may have contributed to Ff Wornham’s deathin that they may have failed to ensure their contractor complied with BS 5839-1:2002;clause 26.2(f) in respect of precluding the use of plastic trunking for securingthe electrical cabling of their common area fire alarm system.

Finally, Firefighters have always known that there are some elements in fire situationsthat are unpredictable and can prove fatal. Thankfully, modern research anddiagnostics have assisted the development of procedures and techniques that minimisethe risks presented by previously unpredictable elements.

However, this report identifies areas of organisational weakness that the FBU believesled to HFRS (primarily) failing to prevent or adequately reduce the known risks thateventually overcame Ff Wornham and Ff Miller on 2nd February 2005. Therecommendations in this report seek to correct those organisational weaknesses so thatother Firefighters facing similar circumstances in the future will benefit from thelessons learnt and the lives sadly lost.

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4 Conclusion

As a result of the findings in this report, the FBU believes that:

HFRS failed to fulfil their statutory duties in accordance with the Fire Services Act2004, Part 2, Section 7 (2)(a), (b) & (d) in that they failed to secure the provision ofthe personnel, services and equipment necessary to respond as the initial attendance tothe fire at Harrow Court; failed to secure adequate provision of training for thepersonnel that formed that insufficient initial response to Harrow Court; and failed tomake sufficient arrangements to obtain the information needed to protect life andproperty in the event of a fire.

HFRS failed to fulfil their duty in accordance with the Health and Safety at Work Act1974, Section 2 (2)(c) in that they failed to provide such information, instruction,training and supervision as is necessary to ensure, so far as is reasonably practicable,the health and safety at work of their employees.

HFRS failed to fulfil their responsibilities in accordance with Regulation 13 of theManagement of Health and Safety at Work Regulations 1999 in that they failed totake account of the capabilities of their employees whilst entrusting tasks to them forwhich HFRS had not ensured they had been adequately trained and competent toundertake.

HFRS failed to satisfactorily follow guidance from Her Majesty’s Inspectorate toensure safe systems of work in respect of Fire Service Manuals:

A Guide to Operational Risk Assessment;Volume 2-Fire Service Operations-Compartment Fires and Ventilation;Volume 2-Fire Service Operations-Incident Command;Volume 4-Fire Service Training-Guidance Compliance Framework for CompartmentFire Behaviour Training;Volume 4-Fire Service Training-Fire Service Manual-Training:Technical Bulleting 1/1997-Breathing Apparatus-Command and Control Procedures.

HFRS failed to ensure their High Rise Incident Procedures were sufficientlycomprehensive in content, adequately resourced or their staff routinely and properlytrained in their application. In particular, HFRS failed to take account ofrecommendations following the HSE Improvement Notice awarded to the StrathclydeFire Board.

HFRS failed to fulfil their obligations to the FBU H&S Investigation in accordancewith the Safety Representative and Safety Committee Regulations 1977 in that theyfailed to cooperate and voluntarily give full disclosure, access to documents, provisionof information/evidence and obstructed the right to have private discussions withemployees whilst at work.

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Stevenage Borough Council (SBC) may have failed to undertake a review of thesmoke alarm installations in the individual flats at Harrow Court to assess theirappropriateness as recommended in BS 5839-6:2004 annex A 4.1 a & b and 5.1 a, b& c.

SBC may have failed to ensure their contractor complied with BS 5839-1: 2002;clause 26.2(f) in respect of precluding the use of plastic trunking for securing theelectrical cabling of their common area fire alarm system.

The conduct of Hertfordshire Fire & Rescue Service significantly contributed to thedeaths of Ff Wornham and Ff Miller.

Stevenage Borough Council (SBC) may have contributed to the deaths of Ff Millerand FF Wornham.

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5 Recommendations

Fire Safety

1. That SBC should undertake a fire risk assessment of all their occupants taking intoaccount their ‘Lifestyles’ to ensure that they have the right kind of smoke detector/s inthe right locations as recommended in BS 5839-6:2004 Annex A 5.1 a, b & c.

2. That SBC should replace the smoke alarms for all their “high risk” tenants such as theelderly, socially deprived, and for any tenants with prepaid electricity meters, to ahard wired smoke alarm with a ‘non removable rechargeable long life battery’, as inthese cases a more reliable power supply is essential, as recommended in; BS 5839-6:2004 Annex A 4.1 a & b.

3. SBC should also create a robust maintenance and testing regime for all theirproperties fitted with smoke alarms, and continue to provide instruction on the use ofthe smoke alarm, how and when to change the batteries and how to ‘prevent falsealarms’ to all their tenants, as recommended in both past and present BritishStandards.

4. That HFRS offer the residents of all high rise residential buildings the opportunity ofhaving a Home Fire Safety Visit.

5. That SBC in consultation with HFRS Fire Safety Department should re-evaluate itsentire fire safety evacuation strategy for blocks of high rise apartments and inparticular the apparent contradiction between the ‘Stay Put’ and ‘evacuation’strategies, and provide explicit direction in what to do in the event of a fire in a flat,and what to do in the event that it becomes necessary to evacuate another flat/s, andentire floor or even the whole building. Subsequently, it would be necessary toreview the fire safety procedure notices ensuring that they give clear instructions to alltheir tenants, visitors and staff on what to do in the event of a fire in any part of thebuilding.

6. That HFRS should ensure that all fire fighters receive regular training in all aspects ofactive fire safety measures in line with Fire Service Manual Volume 3 Fire Safety‘Fire Protection of buildings,’ to ensure that all fire fighters are aware of the impact,the various active fire safety measures may have on their operational procedures.

7. HFRS should also ensure that there are sufficient fire fighters on the initial attendanceso that one fire fighter can be detailed as forward/sector commander, in line with FireService Manual Volume 2 Fire Service Operations ‘Incident Command’, Fire ServiceGuide Volume 3 ‘A guide to operational assessment risk’ Generic Risk Assessment3.2 and their own high Rise procedures OPS 3/088.

8. That SBC should remove all the surface mounted plastic trunking/conduit used toprotect and support the Fire Alarm and Automatic Fire Detection System in theCommon Areas of all their premises, and replace them with a method of cable supportwhich as a minimum conforms to BS 5839- Part 1 : 2002; clause 26.2 (f:);

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Methods of cable support should be such that circuit integrity will not be reducedbelow that afforded by the cable used, and should withstand a similar temperature andduration to that of the cable, while maintaining adequate support.

Note 7.. In effect, this recommendation precludes the use of plastic cable clips, cable ties ortrunking, where these products are the sole means of cable support.

9. That SBC should upgrade Harrow Court so that it meets the requirements of theBuilding Regulations, Approved Document B, BS 5588-5:2004, and BS 5588-1:1990,That SBC should carry out a review of the ventilation strategy for the entire building,to ensure that there is a sufficient supply of fresh air to enable the automatic vents tooperate effectively, and reinstate the opening devices on at least some if not all thewindows in the stair enclosure to provide ‘controlled’ ventilation to the common areasof the building.

10. That HFRS should ensure that all fire fighters receive regular training in all aspects ofcompartment fires and ventilation of high rise buildings in line with Fire ServiceManual Volume 2 Fire Service Operations ‘Compartment Fires and TacticalVentilation and ensure that all their fire fighters are up to date with the operation anduse of the AOVs manual override/control switches and familiar with their location atall high rise buildings to which they form part of the predetermined attendance.

11. That SBC in consultation with HFRS should provide a sign/label for the AOV manualoverride/control switches, so that they can be readily identified as to which vent theyoperate and provide instructions for their use.

12. SBC should immediately carry out a survey of the flats in Harrow Court to ensure thatall the individual dwelling entrance doors are positively self closing and fire resisting,work correctly and if necessary make any adjustments and repairs without furtherdelay.

13. SBC should immediately carry out a survey of each flat in Harrow Court to ensurethat the integrity of the fire resisting entrance /internal hall has not been compromised,that all the internal self closing fire resisting doors are in place and work correctly,and if necessary make any adjustments and repairs without further delay.

14. SBC should provide advice for all residents of Harrow Court of the fire safety strategyof their individual flat and the importance of keeping all self closing doors shutparticularly at night after they have gone to bed as recommended in Section 8 CP3 : 4Part 1. 1962 and all subsequent standards.

15. We are aware that there are proposals contained in the current review beingundertaken by the Buildings Division of the Department for Communities and LocalGovernment (DCLG – formerly ODPM) of Approved Document Part B – 2000 – Firesafety relating to the provision of domestic sprinkler systems in high rise residentialbuildings. We fully support the implementation of this proposal which we believewould have assisted greatly at Harrow Court.

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16. The issue of creating a national (England and Wales) fire and rescue service standardoperating procedures for fire fighting in high rise residential buildings which alignswith the guidance for the fire safety design strategies in such buildings that iscontained in Approved Document Part B and other British Standards needs to beaddressed at a national level. This work needs to be carried out urgently.

17. We are aware that there is a current review being undertaken by the BuildingsDivision of the Department for Communities and Local Government (DCLG –formerly ODPM) of Approved Document Part B – Fire Safety 2000 (ADB), webelieve that in light of the incident at Harrow Court in Stevenage that paragraph 18.12of Section B5 – Access to Buildings for Fire-fighting Personnel should be withdrawnand in all new high rise apartment buildings in excess of 18m in height the staircaseenclosures should be designed and constructed as firefighting shafts and eachfirefighting shaft should incorporate a firefighting lift and a rising main facility withinthe firefighting lobby between the staircase and the accommodation.

18. It is the opinion of the authors that had the design of Harrow Court incorporated twofirefighting shafts both of which incorporated a firefighting lift and a dry rising mainfacility this would have greatly assisted with the fire fighting operations and limitedthe spread of heat and smoke to other parts of the building. It is also very necessarythat the review gives consideration to providing guidance in the ADB replacementdocument to the venting of smoke from access corridors in apartment buildings whichdo not have an external wall. We do not believe that this should be achieved byventing via the staircase enclosure.

19. We are aware that there are proposals contained in the current review beingundertaken by the Buildings Division of the Department for Communities and LocalGovernment (DCLG – formerly ODPM) of Approved Document Part B – 2000 – Firesafety relating to improved corridor smoke ventilation systems in high rise residentialbuildings. We fully support the implementation of this proposal which we believewould have assisted greatly at Harrow Court.

20. That SBC should immediately carry out a survey of the self closing fire resistingdoors through out the common areas of the building to ensure that they are in place,that they work correctly and if necessary make any adjustments and repairs withoutfurther delay, furthermore we recommend that all the above mentioned doors shouldbe fitted with intumescent strips and smoke stop seals.

21. SBC should immediately carry out a strategic review and risk assessment of the firesafety strategy of the building and as part of that process assess the need to;

Upgrade the layout of the ground floor foyer, to one that complies with theApproved Document B 2000 – Fire safety; and

Reinstate open able ventilation windows in the stair enclosures to provide ventilationto the staircase enclosures in the event of a fire.

Move the existing dry riser outlet from the staircase enclosure into corridor and/or Provide a second dry rising main at the far end of the building.

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22. That SBC whilst carrying out the ‘strategic review and risk assessment of the firesafety strategy of the building’ (recommendation number 21), they should alsoprovide the lift shafts with protection from the ingress of water and smoke in line withBS 5588- Part 5: 2004, Section 13 and Annex A.

23. We recommend that whilst under taking all of the above recommendations SBCshould wherever practicable ensure that there fire safety strategy and fire safetymeasures meet the appropriate current guidance or standards.

24. HFRS should ensure that at all fires in High Rise buildings there are sufficient firefighters on the initial attendance to ensure that one fire fighter can be detailed as liftoperator, in line with Fire Service Guide Volume 3 ‘A guide to operationalassessment risk’ Generic Risk Assessment 3.2 and their own high Rise proceduresOPS 3/088.

25. HFRS should ensure that all fire fighters receive regular training and monitoring in allaspects of High Rise procedures and ensure that a bridgehead is set up two floorsbelow the fire floor on every occasion, to ensure that fire fighters do not inadvertentlyopen the lift doors directly into a fire situation.

26. That HFRS amend its Service Information System note OPS 3/088 High RiseIncidents procedures highlighted below, and any other subsequent changes that maybe recommended following the conclusion of this investigation.

To reflect the fact that some high rise buildings, may use chains to secure their dryriser outlets and that it is necessary for bolt croppers to be taken up to the bridgeheadas part of the equipment required by the initial crews.

That there are sufficient fire fighters on the initial attendance, to enable a fire fighterto be immediately deployed to check that the dry riser outlets are closed and have notbeen vandalised on all floors prior to charging, this will also assist in identifyingwhich method has been used to secure the dry riser outlets and ensuring that the rightequipment is taken up to the bridgehead.

27. That HFRS should ensure that all their fire fighters receive regular training andmonitoring in all aspects of High Rise procedures, and ensure that the initial crewstake the correct equipment up to the bridgehead; this could be achieved by theintroduction of a High Rise Pack containing all of the equipment recommended in thepolicy document.

28. That HFRS need to ensure that all their bolt croppers carried on fire appliances are fitfor purpose, sharp enough and regularly maintained to ensure that they can cutthrough the chains securing the dry riser outlets.

29. That HFRS should provide additional resources to enable their fire safety departmentto immediately carry out a risk based inspection programme within the county ofHertfordshire, starting with high rise residential building.

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30. That HFRS should established a formal structure that would allow operational/intervention managers to liaise regularly with the HFRS fire protection managers, sothat they can be fully briefed upon any new or existing buildings in which there arefacilities provided for the assistance and safety of firefighters. Where necessary anyinformation about a building that might be of assistance to firefighters should also beadded to the HFRS 35 Risk Card and placed on the control and command computer,so that it can be passed to any crews mobilised to any incident at such a building.

31. That HFRS should reintroduce the practice of regular inspections of all high risebuilding under section 1(1)(d) of the Fire Service Act 1947 and complete HFRS 35Risk Card which should be carried on all appliances. This process is an ideal methodfor fire fighters to familiarise themselves with the risks associated with any particularbuilding and is recommended by;

The ODPM’s own IRMP Guidance Note 4 recognises the importance of 1(1)(d)visits as a way “to gather operation intelligence,”

Fire Service Guide Volume 3 ‘A guide to operational assessment risk’ Generic RiskAssessment 3.2 also recommends the use of 1(1)(d) inspections on High Risebuilding.

HFRS’s own High Rise Incidents service information note OPS 3/088 states that1(1)(d) inspections should be carried out as a means of pre planning.

That the testing of dry riser mains should form part of any risk based inspection and, That HFRS should cease its policy of charging for the testing of dry riser mains and

encourage all landlords/owns of high rise building to have their dry riser mainstested.

32. That HFRS actively enforce Article 38 of the Fire Safety Order (when implemented)to ensure that the passive and active fire safety measures incorporate into the buildingfor the protection of fire fighters are present and effectively maintained

Personal Protective Equipment

33. That HFRS should commission a full scientific analysis including the appropriate ENand ISO tests are carried out on a number of different samples of complete sets offirefighting PPE to establish whether it confirms to the relevant EN Standards and thatthe PPE is fit for purpose.

34. That BSI and CEN should review the entire specifications for ‘protective clothing forfighters’ in the light of the estimated temperatures that are believed to have occurredand the duration that Ff Wornham was in the risk area.

35. Until the results of these further tests are known, as an additional control measureHFRS should immediately revise its ‘stand alone’ strategy on the wearing of clothesunder the fire kit

36. The HFRS IRMP should be revised to ensure that the services intervention capabilityis sufficiently robust to ensure that the weight and speed of response deliverssufficient firefighters on the initial attendance to ensure that a BAECO will beestablished on every occasion that BA is used.

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37. That HFRS should bring the services ‘rigging on route’ policy to the attention of alloperational personnel, and instruct Crew & Watch managers to ensure that allpersonnel comply with the services policy on all occasions.

Equipment

38. That BSI, CEN and JCDD should review the standards and specifications for allADSU units in the light that the batteries recommended by the manufacture cannot berelied upon at temperature above 55oC and that firefighters are required to work intemperatures far exceeding that, in the case of Harrow court the estimated maximumtemperature ranged was between 800 and 900oC.

39. That HFRS should review its decision to provide ICOM radios to BA wearers as theyare ‘not intrinsically safe,’ there is also have a problem with the ingress of water andthe corrosion of the printed circuit boards, which may have accounted for the poor andintermittent reception during this particular incident, a fault which the manufacturesare aware.

40. That HFRS should ensure that the new integral breathing apparatus communicationequipment is readily available and working, on all its front line pumping appliances.

41. That HFRS should immediately review SIS TECH 2/058 as it refers to the MotorolaGP900 and the PRP 74 as the handheld radios used by the service.

42. That HFRS introduce of a managed track and trace system for all items operationequipment.

43. That HFRS instruct all Watch / Station manages to rigorously monitor the daily BAchecks and ensure that all BA log book are completed accordingly.

Water Supply and Equipment

44. That HFRS immediately commission an in-depth detailed examination into thesuitability of using the Delta H 500 65f for compartment firefighting in high risebuildings.

45. That HFRS should immediately revise its High Rise Incidents procedures taking intoaccount the final outcomes from this particular investigation, the equipment requiredto be taken up to the bridgehead and particular attention should be made to theguidance given with regard to water pressures, flow rates and tactical firefighting .

High Rise Incident Procedures

46. That DCLG should immediately revise the ‘High Rise Incidents’ Generic RiskAssessment GRA 3.2 taking into account the final outcomes from this particularinvestigation, and that of the Petershill Court, Glasgow fire which resulted inStrathclyde FRS receiving an improvement notice dated 29th March 2003, togetherwith the recommendations contained in the following documents;

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BDAG research report, Aspects of High Rise Firefighting (Fire Research TechnicalReport 3/2005 published in December 2004)

Fire Service Circular (FSC) 55-2004, HSE Improvement Notice F210003173 CAST 1, FDR1 Fires: Dwellings; Multiple Occupancy High Rise, 2 to 4 casualties

involved rescue via internal staircase.

47. That HFRS should immediately revise its High Rise Incidents procedures taking intoaccount the final outcomes from this particular investigation, and that of the PetershillCourt, Glasgow fire which resulted in Strathclyde FRS receiving an improvementnotice on the 29th March 2003, together with the recommendations contained in thefollowing documents;

BDAG research report, Aspects of High Rise Firefighting (Fire Research TechnicalReport 3/2005 published in December 2004)

Fire Service Circular (FSC) 55-2004, HSE Improvement Notice F210003173 CAST 1, FDR1 Fires: Dwellings; Multiple Occupancy High Rise, 2 to 4 casualties

involved rescue via internal staircase.

48. The policy should also contain detail on, or ‘make reference to’ where the reader canfind the following information;

Tactical Ventilation Compartment Fires Fire phenomena’s such as Backdraught, Flashover and the previously mentioned

‘Blowtorch’ Fire protection arrangements found in these types of buildings.

49. That HFRS would then have to prepare a new training programme, ensuring that itmeets the requirements of the revised documents and make certain that all personnelreceive centrally delivered practical and theoretical training in the new procedures assoon as reasonably practical.

50. That HFRS should reintroduce the practice of regular inspections of all high risebuilding under section 1(1)(d) of the Fire Service Act 1947 and complete HFRS 35Risk Card which should be carried on all appliances and the services mobilisingcomputer system. This process is an ideal method for fire fighters to familiarisethemselves with the risks associated with any particular building and is recommendedby;

The ODPM’s own IRMP Guidance Note 4 recognises the importance of 1(1)(d)visits as a way “to gather operation intelligence,”

Fire Service Guide Volume 3 ‘A guide to operational assessment risk’ Generic RiskAssessment 3.2 also recommends the use of 1(1)(d) inspections on High Risebuilding.

HFRS’s own High Rise Incidents SIS note OPS 3/088 states that 1(1)(d) inspectionsshould be carried out as a means of pre planning.

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51. This would also require a revision of the HFRS Inspection under Section 1(i)(d) of theFire Services Act , SIS note OPS1/023.

52. The HFRS IRMP should be revised to ensure that the services intervention capabilityis sufficiently robust enough to ensure that the weight and speed of response, deliverssufficient firefighters and operational equipment on the initial attendance to enabletheir High Rise procedures to be implemented in full from the very start of everyincident.

Breathing Apparatus (BA) Procedures

53. We are aware that there is a review currently taking place of TB 1/97 by the BuildingsDivision of the Department for Communities and Local Government (DCLG–formerly the ODPM). We believe that this should include any recommendations thatmay arise from both the Bethnal Green fatal fire and this particular Harrow Courtinvestigation, together with any recommendations that arise from the followingdocuments.

BDAG research report, Aspects of High Rise Firefighting (Fire ResearchTechnical Report 3/2005 published in December 2004) in particular Section 3Compartment firefighting, training and tactics.

Fire Service Circular (FSC) 55-2004 in particular the recommendations in section5.4.

54. That HFRS should immediately revise its Breathing Apparatus procedures and bringthem back into line with TB 1/97. This review will also need to take account of anyrecommendations that may arise from both the Bethnal Green fatal fire and thisparticular Harrow Court investigation, together with any recommendations that mayarise from the following documents.

The revised TB 1/97

Any future revisions to the national ‘Guides to Operational Risk Assessment’(GRA)

55. That HFRS would then have to prepare a new training programme, ensuring that itmeets the requirements of the revised documents referred to above and ensure that alloperational personnel receive centrally delivered practical, theoretical and refreshertraining on BA procedures as soon as reasonably practical.

56. The HFRS IRMP should be revised to ensure that the services intervention capabilityis sufficiently robust to ensure that the weight and speed of response deliverssufficient firefighters and operational equipment on the initial attendance to enabletheir Breathing Apparatus procedures to be implemented in full from the very start ofevery incident.

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Incident Command System (ICS) Procedures

57. That HFRS should immediately revise its Incident Command System and ensure thatit corresponds with the Fire Service Manual Volume 2 Fire Service Operations-Incident Command. This review will also need to take account of anyrecommendations that may have arisen from both the Bethnal Green fatal fire, andPetershill Court, Glasgow fire and this particular Harrow Court investigation.

58. That HFRS would then have to prepare a new training programme, ensuring that itmeets the requirements of the revised Incident Command System referred to aboveand ensure that all operational personnel and supervisory officers receive regularcentrally delivered practical, theoretical and refresher training on as soon asreasonably practical.

59. That HFRS would also have to prepare a new Dynamic Risk Assessment trainingprogramme, ensuring that it meets the requirements of the revised Incident CommandSystem and ensure that all operational personnel and supervisory officers receiveregular centrally delivered practical, theoretical and refresher training on as soon asreasonably practical.

60. That HFRS would also have to prepare a new training programme on RadioProcedures and Messages, ensuring all operational personnel and supervisory officersreceive regular centrally delivered practical, theoretical and refresher training on assoon as reasonably practical.

61. The HFRS IRMP should be revised to ensure that the services intervention capabilityis sufficiently robust to ensure that the weight and speed of response deliverssufficient firefighters and operational equipment on the initial attendance to enabletheir Incident Command System procedures to be implemented in full from the verystart of every incident.

62. That HFRS should purchase sufficient incident command surcoats to ensure eachmajor pumping appliance carry a complete ‘Command Team’ set comprises of :-

Incident Commander Command Support Sector Commanders Safety Officer Operational Commander Inner Cordon Control Officer

Training

63. That HFRS immediately initiate a comprehensive Training Needs Analysis in(accordance with the HMI Fire Service Manual-Volume 4-Fire Service Manual –Training, Section 2.3) for all firefighting staff with a view to developing acomprehensive and properly resourced training programme incorporating delivery atboth the central training centre and at stations.

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64. That HFRS review and properly resource comprehensive Compartment FireBehaviour Training (CFBT) for all RDS and Wholetime Firefighters such that it shallinclude practical fire-attack training.

65. That HFRS review and properly resource BA training such that it shall be a separatecourse from the properly dedicated CFBT course (consistent with the Fire ServiceManual Volume 4: Guidance and Compliance for Framework Compartment FireBehaviour Training: “Training in Compartment Fire Behaviour and CompartmentFirefighting should not be confused with other Breathing Apparatus heat and smoketraining which has different aims and objectives associated with acquiring the skillsnecessary to wear Breathing Apparatus”).

66. That HFRS review and properly resource Breathing Apparatus procedures andtraining consistent with HMI technical bulletin 1/97.

67. That HFRS review and properly resource joined-up, theoretical and practical HighRise Incident training consistent with revised standard operating procedures in thelight of the Harrow Court incident and the recommendations following the HSEImprovement Notice awarded to the Strathclyde Fire Board.

68. That HFRS reintroduce the systematic, frequent inspection of High Rise premises intheir territory and ensure a programme of systematic regular familiarisation trainingfor fire crews local to those premises.

69. That HFRS review Incident Command procedures to ensure that they are fit forpurpose; ensure the necessary competencies of Initial Incident Commanders for theincident types they will be required to lead; and properly resource regular, practicaltraining for all levels of operational managers and firefighters in the application ofappropriate Incident Command procedures.

70. That HFRS secure the comprehensive Junior Officer courses available at the FireService College for all operational Crew Managers and Watch Managers.

71. That HFRS ensure that the Service Monitoring procedure SIS OPS 2/070 - thatrequires the attendance of a Supervisory Officer to ‘MONITOR’ fire servicepersonnel at an incident in respect of their operational performance so that anyweaknesses identified can be included in any training needs analysis - is adhered toand management structures sufficiently resourced. This to include the monitoring ofIncident Command performance.

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72. That HFRS review and properly resource all operational training to ensure that allRDS and Wholetime firefighting personnel receive regular training to ensure that theyare competent to:

Understand the burning characteristics, development and behaviour ofcompartment fires;

Recognise and assess the risks involved when dealing with compartment fires; Prevent flashover and backdraught or mitigate their effects where possible; Implement control measures to protect themselves from the effects of fire; Recognise the operating limitations of Firefighters’ Personal Protective

Equipment (PPE) and fire fighting ancillary equipment; Control and extinguish fires with minimum risk to their own and others’ safety; Understand the principals of Incident Command; Recognise and understand the appropriate application of offensive and defensive

Firefighting; Apply appropriate offensive and defensive fire-attack techniques; Implement appropriately revised and updated High Rise Incident procedures; Implement appropriately revised BA procedures consistent with HMI technical

bulletin 1/97.

Accident Investigation Protocol

73. That HFRS and FBU jointly review SIS note H&S 1/008 ‘Reporting and Investigationof Accidents and Incidents’ in particular Section 1 ‘All Accidents-Reporting andRecording’; and should also ensure that the Safety representatives are informed of allaccidents immediately; and Section 4 ‘Disclosure of information’ is expanded toinclude either a protocol for a joint investigation, or a protocol that protects the safetyrepresentatives rights to full disclosure, access to documents, the provision ofinformation/evidence, and the right to have private discussions with employees.

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