Fatal Accident Investigation Report...Marlie Farm in East Sussex, Atherstone-on-Stour in...

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Fatal AccidentInvestigation Report

Into the death of firefighter Ewan Williamson

at The Balmoral BarDalry Road, Edinburgh

Sunday 12 July 2009

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Fatal AccidentInvestigation Report

Into the death of firefighter Ewan Williamson

at The Balmoral BarDalry Road, Edinburgh

Sunday 12 July 2009



This report was carried out in accordance with;• Health and Safety at Work Act 1974• Management of Health and Safety at Work Regulations 1999• Safety Representatives and Safety Committees Regulations 1977

We reserve the right to amend or modify the contents of this report.

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You may re-use this document (not including any logos) free of charge in any format or medium.You must re-use it accurately and not in a misleading context. The material must be acknowledged asproperty of The Fire Brigades Union and you must give the title of the source publication. This publicationis available at www.fbu.org.uk and www.fbuscotland.org

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All rights reserved.

FBU were unable to release this Report for publication until completion of the criminal proceedingsagainst Scottish Fire and Rescue Service

Fatal Accident Investigation Report

On the 12th July 2009 whilst employed by Lothian and Borders Fire and Rescue Service and attending anincident involving a fire in the basement of a public bar which also required multiple rescues from thetenement above, in the early hours of the morning Ewan lost his life. This is the report of the Fire BrigadesUnion health and safety investigators, David Bennett and Andy Fulton.

This incident was another tragic and unacceptable instance of a firefighter killed in the line of duty. In the last10 years, 15 firefighters have been killed at fires. Bethnal Green in London, Harrow Court in Hertfordshire,Marlie Farm in East Sussex, Atherstone-on-Stour in Warwickshire; and since Ewan Williamson lost his lifeanother two firefighters were killed in a fire at Shirley Towers in Southampton. It is clear to the FBU thatGovernments and Fire Services across the UK are not learning the lessons from any of the previousfirefighter fatalities; that is totally unacceptable.

As the union which serves the firefighters of the UK, it is our duty to investigate the causes (direct orunderlying), behind any such incident such as this in order to learn from it and attempt to prevent anyreoccurrences.

In 2005/6 the FBU objected to the removal of advisory structures such as the Central Fire Brigades AdvisoryCouncil (CFBAC) and its Scottish equivalent (SFBAC), and the changes to the inspection regime by HerMajesty’s Inspectorate, which were defined under the previous 1947 Act. Both the advisory councilsensured that consensually agreed procedures and standards were promulgated to the service.

This ended in 2006 upon the introduction of the new Fire Services Act which, in the opinion of the FBU, didnot offer a suitable or sufficient replacement of this proven advisory structure which provided guidance andtechnical advice to the fire sector.

The role of the HMI was also changed to that of an advisory capacity (Scottish Fire and Rescue AdvisoryUnit) to the Minister and moved away from any inspection of policies, procedures and compliance with anystandards; self or peer inspections became the norm. Any new structure of the UK FRS must redress thesedangerous errors and must include both an advisory structure for guidance and standards and anindependent inspection regime which has the confidence of the fire sector.

The tragic loss of Ewan also highlighted a common issue; the lack of agreement between all the interestedparties on the best way to proceed with any investigation. No memorandum of understanding was, or is, inplace between the HSE, FRS, the Police and the FBU. This was not helpful when embarking on such aserious matter and should be addressed in any restructure of the Scottish Fire and Rescue Service.

Throughout the course of the investigation there were many areas of concern that were highlighted toLothian & Borders FRS, many of which remain outstanding. This is clearly a concern as we believe everyissue highlighted has a significant impact on firefighter safety. It would appear that some of these have notbeen acted upon immediately, possibly due to fear of an admission of guilt or liability; this is extremelyworrying and measures to help enable these issues to be addressed as soon as possible requires urgentagreement.

Before we can learn from any incident we must first understand what occurred and why. The reportexamines the areas immediately around the incident, some of the Lothian & Borders Fire and RescueService training regime and the information available to crews in the build up to their attendance.

There are many failures apparent from this incident that are outside the scope of the investigation. It is theFBU’s opinion that there may be some unsafe practices in Lothian & Borders FRS in that, they do notalways train staff appropriately for all risks, do not pre-plan suitably for dealing with all foreseeable incidents,

do not risk assess all foreseeable incidents accurately and therefore continue unnecessarily to putfirefighters’ lives at risk on a daily basis.

What is clear is that Ewan became separated from his Breathing Apparatus partner. He became trappedand despite the desperate best efforts of his comrades he died.

These failures have been present in other Fire and Rescue Services and at other incidents where firefightershave been killed during the course of their work. It is clear that this cannot be allowed to continue.

This report was compiled with the co operation of all FBU members and officials by the FBU investigationteam, working within the guidance of the FBU Serious Accident Investigator manual.

Roddy RobertsonExecutive Council MemberRegion 1 (Scotland)

Fatal accident at The Balmoral Bar, 178-182 Dalry Road, Edinburgh

Sunday 12th July 2009LBFRS Incident No. 10161

Preface

The PurposeThe purpose of this report is to establish the immediate and underlying causes of the death of FirefighterEwan Williamson, by analysis of operations used during the incident. By sequential analysis the investigationteam have established the adequacy of work systems and have made recommendations to improve riskcontrol systems identified in Chapter 6.

Accidents can occur through people’s involvement with their work. As technical systems have becomemore reliable, the focus has turned to human causes of accidents. It is estimated that up to 80% ofaccidents1 may be attributed, at least in part, to the actions or omissions of people. This is not surprisingsince people are involved throughout the life cycle of an organisation, from design through to operation,maintenance, management and demolition.

Many accidents are blamed on the actions or omissions of an individual who was directly involved inoperational or maintenance work. This typical but short-sighted response ignores the fundamental failureswhich led to the accident. These are usually rooted deeper in the organisation’s design, management anddecision-making functions.

This report is not intended to apportion blame on any individual.

The ProcessThe investigation team has used the Fire Brigades Union Serious Accident Investigation Manual (FBU SAIManual) as its guide for the investigation and to produce this report.

What is a Serious Accident Investigation?It is a systematic process which promotes a logical, consistent and professional approach to theinvestigation of safety events following systems failures that have resulted in or had the potential to causedeath, serious injury or major equipment failure, while providing an impartial and independent evaluation ofthe events which lead to the failure.

The investigation team has used the main headings within the FBU SAI Manual to set out the report.These headings are:

• Evidence collection;• Analysis of evidence – Urgent risk critical factors:

– Immediate causes;– Underlying causes;– Conclusions.

• Recommendations.

The main report starts from the time the first call was received by Lothian and Borders Fire and RescueControl Room at 00:38 and has included events up to 03:21, which is the time Ewan Williamson waspronounced dead.

Key InformationAll references to appliance call signs, acronyms, fire service terminology and recognised abbreviations aredetailed in Section 7 – References, at the end of this report.

Contents

1 Synopsis ....................................................................................................................................................................................................3

2 Sequence of Events .........................................................................................................................................................................4

3 Evidence Collection ......................................................................................................................................................................15A Evidence collection....................................................................................................................................................................15B Interviews ........................................................................................................................................................................................15C Photographs .................................................................................................................................................................................15D CCTV Footage.............................................................................................................................................................................15

4 Analysis of Evidence ....................................................................................................................................................................17A Approach to analysing evidence.......................................................................................................................................17B What happened?........................................................................................................................................................................17C How did it happen? ..................................................................................................................................................................18D Why did it happen?

Immediate causes .....................................................................................................................................................................18E Why did it happen?

Underlying causes identified by the incident .............................................................................................................31F Why did it happen?

Organisational underlying causes ....................................................................................................................................52

5 Conclusions.........................................................................................................................................................................................64

6 Recommendations ........................................................................................................................................................................75

7 References ...........................................................................................................................................................................................77

8 Appendices ..........................................................................................................................................................................................83(Appendices documentation included on disc)

9 Sources ...................................................................................................................................................................................................84

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1 Synopsis

Date: 12th July 2009

Time: Between 00:38 (time of first call) and 03:21(when Ewan Williamson was pronounced dead)

Investigators: David Bennett (Lothian & Borders FBU Health & Safety Representative)Andy Fulton (Lothian & Borders FBU Brigade Secretary)

Incident No.: Lothian & Borders Fire & Rescue Service Incident No. 10161 (2009)

Location: The Balmoral Bar, 178-182 Dalry Road, Edinburgh, EH11 2EG.Basement/Ground Floor

Incident details: Mobilisation to fire in a building.BA Team became separated with one BA Wearer becoming trapped.

Injuries: FF Ewan WilliamsonFF Williamson was exposed to fire and extreme heat, lost consciousness and died2.

Event: FF Williamson was separated from his BA partner and became trapped in a toilet. Firespread through basement causing structural collapse of ground floor cutting off hismeans of escape.

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2 Sequence of Events

To assist readers understanding, below is a brief description of the premises and its contents. It may be offurther assistance to refer to:

• Photographs of each sector (Appendix 1);• Premises Plan showing Balmoral Bar ground floor and basement (Appendix 2).

The bar is located within a stone built tenement, located on the corner of Dalry Road and Downfield Place.

The Balmoral Bar accommodates the ground floor and basement of the tenement, with three floors abovebeing private dwelling flats.

The Balmoral Bar extends approximately 20 metres from the front entrance, on Dalry Road, to the rear walland approximately 30 metres wide.

There are two emergency exits from the bar. One at the rear of the premises adjacent to the toilets. Thisescape exits to the garden at the rear. The second emergency exit is located at the top of the stairs to thebasement. This escape exits into the common stair at No. 1 Downfield Place.

Access to the basement of the Balmoral Bar is located down a stairwell at the rear of the bar area. Thebasement extends under the whole of the ground floor bar area with an office area located at thefurthermost point from the stairs.

An access hatch to the basement is located outside in Downfield Place.

Separate access to the flats directly above the bar is gained through the tenement stair at No. 1 DownfieldPlace. This common stair gives access to all floors in this tenement and also access to the rear through abasement passage. There is one flat, on the ground floor of No. 1 Downfield Place. There are fifteen flatsabove the ground floor, five on each of the floors.

Access from Dalry Road to the rear is gained through the tenement stair at 172 Dalry Road.

For the ease of the reader, appliance crew lists are available in Section 7.

All the information included in the sequence of events has been gathered from witness interviews,photographs and CCTV footage.

BA Teams are numbered only when they have been committed within the bar or the tenement stair at No.1Downfield Place.

00:38 Time of callLothian and Borders Fire and Rescue Service (LBFRS) received an emergency call at 00:38 onSunday 12th July 2009. The caller stated that the pub [the Balmoral Bar] was on fire. This wasfurther corroborated by a telephone call from Lothian & Borders Police (LBP) confirming that theyhad received a call from the bar staff that ‘the place was up in flames’. In total there were seven callsto LBFRS Control Room reporting the same incident.

On receipt of the initial call, LBFRS Control Staff mobilised a pre-determined attendance (PDA) ofthree pumping appliances, call signs 301, 302 and 311 and a Turntable Ladder (TTL) call sign 303.The total number of personnel in the initial mobilisation was 16 Firefighters.

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00:42 Appliances 301 and 302 in attendance The first appliances on the scene were 301 and 302, both pumps arriving at 00:42. On arrival it wasobvious to the crews that there was a well developed fire with a significant volume of smoke issuingfrom the Balmoral Bar. Several people were seen at windows in the flats above the bar.

The Incident Commander (IC), Watch Manager (WM) made contact with the bar managerwho explained that the fire was located in the basement office at the rear of the bar. WM wasgiven a route to the basement from the bar manager.

00:43 Appliance 303 in attendanceWhen the TTL arrived, it was deployed to carry out rescues from the flats in Dalry Road andDownfield Place. The TTL was pitched on the corner of Dalry Road and Downfield Place andfirefighters began to effect rescues from the tenement flats.

00:45 Appliance 311 in attendanceA Breathing Apparatus Entry Control Point (BAECP) was established near to the front entrance ofthe bar and by 00:46 WM committed two Breathing Apparatus (BA) teams into the bar tosearch for and extinguish the fire in the basement. These two teams entered the bar with a chargedlength of 45mm hose and Thermal Image Camera (TIC).

The first BA teams committed into the bar were Firefighter (FF) and FF Williamson (Team 1)and FF and FF (Team 2).

Two further BA wearers from 311 were quickly deployed to begin searching the tenement at 1Downfield Place. FF and FF (Team 3) were briefed by WM to makecontact with the residents in the flats and prioritise for rescue.

00:47 First informative message sent from 301: “IC Fire within basement, at work with6BA and 1 line of hose, Offensive mode.” This message was quickly followed by anothermessage stating “Stage 2 Entry Control now in operation.”At this time Control mobilise Flexi Duty System (FDS) Officer call sign 30, from his homeaddress, initially as Incident Commander.

On receipt of the ‘Stage 2 BA Entry Control’ message, Control confirmed a ‘Make pumps 4’. Onreceiving confirmation of ‘Make pumps 4’ (00:50), Control mobilised an additional pump (512),Command Support Unit (CSU) (325), Major Incident Unit (MIU) (364) and Fire Investigation Unit (FIU)(564). FDS Officer call sign 12, is mobilised as 4 – 5 Pump Officer.

00:52 Informative message from 301: “IC Ambulance required for 1 child under age of 1,conscious and breathing suffering smoke inhalation.”Rescues from the flats facing the street are carried out using the TTL and a short extension ladder.FF FF and WM rescue an infant from the first floor. Other people werebrought down using the TTL. During this period, BA Team 3 are progressing through the stairmaking contact with and reassuring residents before they can be rescued. BA Team 3 cannot affectany rescues because of the thick smoke throughout the common stair.

In the bar, BA Teams 1 and 2 are experiencing difficulties in locating the stairs to the basement.They are hampered by zero visibility, a significant amount of heat, the confined nature of the areabehind the bar combined with the presence of the charged 45mm hose. The TIC is of limited usedue to the display and BA face mask constantly ‘sooting up’. At one point Team 2 return to thepoint of entry to ask for more information on the location of the stairs.

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00:55 Assistance message sent from 301: “Make pumps 5.”On receipt of this message Control mobilise a fifth pump (502), Incident Support Unit (ISU) (524), BASupport Vehicle (86).

Inside the bar, the BA Teams locate the stairs and Team 1 descends into the basement with the lineof hose. There is a noticeable rise in the temperature when descending the stairs. Team 2 assistwith the hose ensuring that the firefighting team are not hampered in making progress in thebasement. Team 2 remain at the door to the stairs and do not descend. When Team 1 leaves thestairwell and enters the main basement area, the heat increases again. Water is pulsed into theceiling but the fire was not located.

00:59 Appliance 512 in attendanceOn arrival Crew Manager (CM) makes contact with the IC. The IC takes CM FF and FF to Downfield Place and examines the beer delivery hatch as ameans of access to the basement. The IC details CM and his crew to force entry into thebeer delivery hatch.

FDS Officer mobilised (00:58) as Safety Commander and FDS Officer mobilised (01:00) as Logistical Support Officer (LSO)

01:00 Informative message sent from 301: “6 BA & 1 Line of hose in use TTL in use, 6 personsremoved from building, Offensive mode.”Rescues are continuing from the front of the building. The TTL rescues 5 adults from the first,second and third floors. All are walked down the TTL.

01:02 A further informative message is sent by 301: “IC This is a 4 storey building approx20 x 20M, Fire within basement & ground floor.”

01:03 Appliances 502, 325 and 86 in attendance

01:04 Informative message from 301: “This incident has been sectorised, Sector 1 – WM Sector 2 – CM in charge, Sector 3 – WM in charge.”Incident Commander sectorised the incident. Sector 1 is the front of the bar on Dalry Road, Sector2 is Downfield Place, and Sector 3 is the rear garden.

On arrival, the crew of 502, CM FF and FF approach the IC inSector 1. FF and FF are rigged in BA (BA Team 4).

Inside the bar, Team 1 has still not located the fire and after a BA gauge check they decide that it istime to exit the building. The branch is left approximately two metres into the basement. Team 1ascend the stairs and along with Team 2 proceed to exit the bar. Both teams exit the bar atapproximately 01:07 and are debriefed by IC. They have been inside the bar for about 22 minutes.

The IC takes BA Team 4 to Downfield Place where the beer hatch is in the process of beingopened. BA Team 4 set up a line of hose to cover the hatch. When the beer hatch is openedvolumes of dark grey smoke rises from the beer hatch. The IC decides it is not a suitable accesspoint. The beer hatch is left open.

BA Teams 1 and 2 change the cylinders on their BA sets ready to be redeployed. Spare cylindersare supplied. During this period, all the BA wearers remove their flash hoods and open their tunics.Water is provided and consumed by all four BA Wearers.

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The IC takes BA Team 4 back to Sector 1 and they are committed to the bar from Sector 1 ECP.BA Team 4 is briefed to proceed to the basement, find the branch and continue to try to locate andextinguish the fire. They enter the bar with a high pressure hose reel jet (HRJ) for protection.

01:05 Appliance 364 in attendance


01:09 FDS Officer in attendanceFDS Officer reported to the CSU, handed in his cordon tally and informed the CSU that hewould be assuming command after liaising with IC

BA Team 4 reaches the branch in the basement and advance toward the fire. They advancethrough the beer cellar doors but still do not reach the seat of the fire.

BA Team 3 exit the tenement stair in Downfield Place, they have made contact with residents onground, first and second floors. A further BA Team, FF and FF (Team 5) aredeployed into the tenement stair in Downfield Place. They enter the building with resuscitationequipment and an ‘enforcer’ door opener. They are briefed to enter all the flats.

01:14 Informative message from CSU: “GM is now OIC of incident.”Group Manager (GM) takes charge of the incident and WM is now appointed as SectorCommander (SC), Sector 1.

01:17 BA Team 1 are re-committed into the barAt 01:17, BA Team 1, FF and FF Williamson are re-committed into the bar. They have beenoutside the bar for approximately 10 minutes. They are asked by SC if they are ‘good to go’.When FF and FF Williamson confirm that they are ready to be redeployed they are briefedto retrace their steps to the basement, locate the branch and continue firefighting. BA Team 1re-enter the bar with a HRJ for protection.

SC takes BA Team 2 around to Downfield Place to inspect the beer delivery hatch. SC again considers this as a means of entry. BA Team 2 is unsure about where the delivery hatch leadsand suggests that they are recommitted through the front door. SC and BA Team 2 proceedback to ECP in Sector 1. The delivery hatch is left open.

At approximately 01:18, CM is detailed to break all the windows at the front of the bar. At,approximately, 01:19 a radio message is passed by WM to indicate to the BA Teams that thewindows are about to be smashed. BA Team 4 is still at the branch in the basement and receive themessage but do not respond.

The bar windows are smashed and FF commented that the temperature inside the bar ‘didrocket up’. BA Team 4 makes their way out of the basement and encounter BA Team 1 at the footof the stairs. A short briefing is carried out between BA Team 4 and BA Team 1. BA team 1 continuetowards the branch and BA Team 4 makes their way out of the bar.

BA Team 2 is briefed to re-enter the bar and proceed to the basement to assist Team 1 in fightingthe fire. At approximately 01:22, BA Team 2 re-enter the bar.

Meanwhile, BA Team 5 has reached the second floor, flat 2. They discover two adults and a youngchild in distress. The child is given oxygen and BA Team 5 requests a ladder to be pitched to therear of the building to affect rescue. A 10.5m ladder is used to remove the family from the building.

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A BA Emergency Team is requested by SC and FF and FF get rigged inBA and wait by the BAECP in Sector 1.

Back in the bar, BA Team 2 encountered BA Team 1 coming up the stairs from the basement. BATeam 1 could be heard shouting to each other about the heat in the basement, they continue upthe stairs and past BA Team 2 FF (BA Team 2) states that he hears FF Williamson say “I’mgoing outside I’m fucked with the heat.” FF Williamson is behind but in touch with FF

01:29 Assistance Message from CSU: “Make Pumps 7 for BA wearers.”

01:29 FF exits the bar.FF exits the bar alone. FF is asked where FF Williamson is and he replies ‘he’sright behind me’. SC contacts FF Williamson on the radio and stated that FF Williamsonreplies ‘I’ll be there in a minute Boss, I think I’m stuck in a toilet.’ On realising that FF Williamson hasnot exited the bar, FF re-enters the bar to search for him. SC attempts to stop FF

re-entering the bar and crawls in after him. SC exits the bar almost immediately dueto the smoke.

At the same time, BA Team 2 reaches the top of the stairs and attempt to descend into thebasement. BA Team 2 is prevented from descending the stairs because of the heat. They spraywater down the stair in an attempt to cool the area. This makes no difference and they decide toexit the bar.

FF Williamson is heard on the fireground radio saying ‘I’m still stuck, I’m still stuck.’ SC instructs FF Williamson to activate his (Automatic) Distress Signal Unit (ADSU). There is no responsefrom FF Williamson to this message.

BA Team 2 encounters FF at the end of the bar. The three BA Wearers then proceedfurther into the bar to search for FF Williamson but as the heat is intensifying and they do not have aHRJ for protection they stop and return towards the exit. They do not hear an ADSU sounding.

Immediately on exiting the bar, BA Team 2 service their BA sets to make themselves available foranother entry.

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Photograph taken from Dalry Road looking through to the rear of bar and Gents toilets

Gaming machines

Gents toilets

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01:34 Assistance message from 325: “This is a BA Emergency, 325 over.”WM informs IC that he has declared a BA Emergency. This message is passed over thefireground radio.

On receipt of the BA emergency message, Fire Control contact the Scottish Ambulance Service(SAS), Area Manager (AM) and mobilised a further pump (501). It took over two minutes forSAS to answer the call from Fire Control.

A line of hose is already set up in Downfield Place and a BA Team (FF and FF areinstructed to direct the jet down the beer hatch.

01:36 Appliance 331 in attendanceAt approximately 01:36, BA Emergency Team 1 (FF and FF is committed intothe bar to search for FF Williamson. They were briefed by WM The likely location of FFWilliamson was in the toilets at the rear of the bar. BA Emergency Team 1 enters the bar withoutequipment or any means of firefighting.

FF and FF returned to Sector 1 ECP, approximately six minutes after they exited thebar. They had serviced their BA sets and were committed for a third time into the bar to assist BAEmergency Team 1. They were re-committed approximately two minutes after BA EmergencyTeam 1, they also enter without equipment or any means of firefighting.

Both teams were briefed to proceed to the last known location of FF Williamson. This was in thetoilets at the rear right hand side of the bar, past the gaming machines.

BA Team 4 are positioned outside the bar with a line of hose, they are instructed to provide coverfor the BA Emergency Teams and direct the jet through the broken windows towards the rear of thebar and toilets.

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Photograph taken from the rear of 172 Dalry Road – Sector 3

Emergency exit– Sector 3

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At approximately 01:39, Temporary Area Manager (T/AM) assumes the role of IncidentCommander. GM becomes the Operations Commander. The Commander for each of thethree sectors remains unchanged. This is not communicated back to Fire Control.


01:39 Appliance 501 mobilisedEmergency Teams 1 and 2 meet at the end of the bar. They proceeded, on a left hand route, pastthe gaming machines, towards the rear of the bar and the toilets.

Meanwhile, BA Team 3 who were deployed at the beer hatch are redeployed just inside theentrance to the bar with a line of hose. They are instructed to provide cover for the BA EmergencyTeams and direct the jet towards the rear of the bar and the toilets.

BA Team 4 is recommitted to the bar and is briefed to proceed to the basement and continuefirefighting. They make steady progress towards the basement following the hose and proceeddown the stairs.

The emergency exit in Sector 3 identified (approximately 01:45)

A 13.5m ladder is taken to Sector 3 and several rescues are carried out at the rear of the premises.A firefighter is detailed to gain access to the emergency exit which leads out into Sector 3.

This emergency exit is identified as an alternative means of access to the bar.

At approximately 01:46, BA Team 5 is re-committed into the tenement flats on Downfield Place.They were tasked to proceed to the second floor and clear the rest of the flats.

Inside the bar, BA Emergency Team 1 shouts out that they had found a doorway. This doorwayleads into the ladies toilets. At the same time, BA Emergency Team 2 move to their right andencountered what they believed to be another doorway leading into the gents toilets.

FF pushed on this door to the gents toilets, but could not get it to open. Almost immediately,FF shouted out that the floor was about to collapse. As FF pushed harder he felt thedoor move and felt the floor collapsing below him. At this point FF was engulfed in flames andpartially falls through the floor.

BA Team 3 with the hose, at the entrance to the bar, retreats outside because they hear a collapsebut still direct the jet into the rear of the bar.

Aided by FF FF scrambles away from the collapsed floor. Momentarily, they becameseparated but quickly regroup, however, they are disorientated and do not know which direction togo in.

01:47 Appliance 501 (BA Emergency Pump) in attendanceFF and FF were still on the left hand wall, just outside the ladies toilets, when thefloor collapsed. After the collapse, there was a significant increase in heat. They rapidly make their wayout of the bar keeping as close to the wall as possible. Once at the front bar area, the floor becamemore solid and they were able to reach the front door. They exit the bar at approximately 01:48.

FF and FF manage to find their bearings using a jet directed into the bar from outside,both make their way out of the bar. They exit the bar at approximately 01:49.

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During their time inside the bar, neither of the BA Emergency Teams heard an ADSU sounding.

Both Emergency Teams 1 and 2 reported to IC and SC that the floor had collapsed and that it wasunsafe to commit BA crews to this area.

BA Team 4 is still in the basement and has located the branch but do not find the fire. Thetemperature is significantly hotter and they decide to retreat because they are concerned that thefire may be affecting the stairs into the basement.

FF and FF (BA Team 6) are briefed to enter the bar and take a left hand route on theground floor to try to access the toilets at the rear of the pub. They enter the bar with a HRJ. Veryquickly afterwards, FF and FF (BA Team 7) are briefed to take a right hand routeon the ground floor, again to try to access the toilets.

As they are proceeding on their left hand route, BA Team 6 meets BA Team 4 exiting the bar. BATeam 4 exit at approximately 01:51.

01:52 FF Williamson Calculated Time of Whistle (ToW)FF Williamson was committed into the bar with FF at 01:17. FF Williamson’s cylindercontents were recorded on the BAECB as 200 BAR. His calculated ToW was recorded as 01:52(see Section 7).

At approximately 01:53, FF and FF (BA Team 8) are briefed to enter the barand proceed to the basement to continue firefighting. They enter the bar with a 45mm line of hoseand are assisted by CM and FF (BA Team 9).

01:54 Assistance Message from CSU: “AM Make Pumps 9.”On receipt of this message the Fire Control Operators immediately mobilise one pump (312) butthey are unclear how many additional pumps are required. There is a discussion off radio if theMake Pumps 9 includes the pump mobilised for the BA Emergency.

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Photograph taken from the rear of 172 Dalry Road – Sector 3

Acess toGents toilets

Emergency exit– Sector 3

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Fire Control Operators telephone the CSU to clarify how many additional pumps are required. It isconfirmed (01:57) by the CSU that the Make Pumps 9 does not include the BA Emergency Pump.Fire Control immediately mobilise one additional pump (392).

Inside the pub, BA Team 6 reach the end of the bar and the gaming machines and try to progresstoward the rear of the pub. They are uncertain of the condition of the floor as it feels unstable. Theyare unable to move very far into the rear of the pub but attack the fire above them. On the righthand side of the bar, BA Team 7 also encounters the unstable floor. They cannot progress very farand also attack the fire from their position.

BA Team 8 has proceeded into the basement with a line of hose and follows the existing hosetowards the in situ branch. They progress a further two metres into the basement and locate anarea of fire about four metres in front. They attack the fire but do not manage to knock it back.

02:02 FF Williamson’s cylinder contents (calculated) expire.Using the guidance given in TB1/973 a 10 minutes safety margin is included in the consumption ofair calculation. FF Williamson calculated ToW was 01:52.

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Photograph taken in the rear of 172 Dalry Road

Photograph taken in the rear of 172 Dalry Road

BA Team 6 exits the bar and reports the situation with the floor to ECO. They are sent back in with ashort extension ladder to attempt to bridge the gap in the collapsed floor. Back inside the bar theyare not confident that any suitable structure remains for them to bridge across and pass the ladderto BA Team 7 for an attempt from the right hand side. BA Team 7 decides that it is too dangerousto attempt to bridge the collapsed floor.

At approximately 02:09, BA Team 9 is approaching ToW and exit the bar. Shortly after BA Team 6, 7and 8 exit the bar.

02:07 Telephone message from CSU: “Lots of cylinders required at this incident.”The CSU telephone Fire Control and request that the Logistical Support Officer (LSO) arrange for fullBA cylinders to be delivered to the incident.

In Sector 3 at the rear of the bar, at approximately 02:09, FF and FF (BA Team 10)are briefed to enter on a left hand route to find the gents toilets. The emergency exit in Sector 3 isopen and there is an internal door leading into the bar which is ajar. When they are committed theyare unable to proceed through the internal door because of the floor collapse. They quickly exit thebar. An ADSU was audible from inside the emergency exit.

The window to the left of the emergency exit is identified as a possible entry into the toilets.The window had several layers of security, metal bars, heavy gauge wire mesh and a heavy steelplate.

When BA Team 10 exited the bar, an angle grinder was being used to try to remove the securitymeasures from the window. It is quickly apparent that heavier equipment was required to gainaccess through the window. At approximately 02:12 the crew of 364 are asked to provideequipment and gain access through the window.

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Photograph taken from inside the bar looking towards therear external wall

Window openingfrom Sector 3

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02:20 Informative Message from CSU: “AM now OIC.”The last resident from the tenement stair is rescued from the building by TTL. In total the crews haverescued 15 adults, one child and one infant.

FF is taken by ambulance to Edinburgh Royal Infirmary.

At approximately 02:26, a Stihl saw is taken through the stair at 172 Dalry Road. This was used toremove the security from the window. The crews experience significant difficulties when cuttingthrough the metal work. Once the metal work was removed, the crews still had to cut throughlayers of plywood, plasterboard, tiles and timber framing. In total this took approximately 27minutes.

BA Team 10 was briefed before the window was open to enter and search the toilet area. As soonas there is an opening BA Team 10 are ready to be committed.

FF is first to enter the toilet and immediately encounters Ewan Williamson underneath thewindow opening. Conditions inside the toilet are precarious, with significant heat, heavy smokelogging and the collapsed floor. FF enters the toilet to assist. They are restricted in movingaround because of the collapsed floor and struggle to move Ewan.

FF and FF (BA Team 11) are deployed to assist and between the two crewsthey finally remove Ewan at approximately 03:03.

Paramedics are waiting for Ewan to be removed from the building and by 03:05 he has been takenthrough the close to the waiting ambulance. Prior to the ambulance departing, the ADSU, whichwas sounding, was removed from Ewan’s BA Set.

Ewan was taken to Edinburgh Royal Infirmary where he was pronounced dead at 03:21.

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3 Evidence Collection

A Evidence collectionThe evidence collected during the investigation is divided into the following:• Witness interviews4

• Personal statements5

• Photographs (Appendices 3 to 7)• CCTV Footage• Recordings from LBFRS Fire Control Room6

• Mobilisation message (Appendix 24)• Plan drawings (Appendix 2)• Training records7

• Supplementary evidence

B InterviewsInterviewing witnesses was a lengthy and time consuming task. Access was not given to Lothian &Borders Police interviews which meant that each person interviewed by the Police required a furtherinterview for this investigation.

To alleviate the burden on each of the witnesses, joint interviews were conducted with LBFRSAccident Investigation Team. LBFRS recorded and transcribed all of the joint interviews.

All of the interviews were conducted on Fire Service premises.

In total, 51 joint interviews were conducted with LBFRS and one interview separately. Twoindividuals refused to take part in an FBU interview. Both of these interview transcripts were securedfrom LBFRS using Freedom Of Information (Scotland) Act 2000 (FOISA). A further eight interviewswere conducted by LBFRS. Access to these interviews was applied for using FOISA, but on appealthis was refused by the Scottish Information Minister.

Where extracts from interviews have been used they are shown in italics. Each extract also includesthe relevant page number(s) and transcript number.

C PhotographsThere are five types of photographs included as evidence. The photographs have been selectedfrom;• LBFRS Photographs taken during the incident, by LBFRS FIU (Appendix 3)• LBFRS Photographs taken later on 12th July, by the LBFRS FIU (Appendix 4)• FBU Photographs taken on 12th July after the fire had been extinguished (Appendix 5)• FBU Photographs taken inside the bar on 7th October 2009 (Appendix 6)• FBU Photographs taken on 31st May 2010 (Appendix 7)

LBFRS refused to provide electronic copies of the photographs taken at the incident. The imagesincluded in the appendices have been scanned resulting in significantly poorer quality thandesired.

D CCTV FootageCCTV footage of the incident has been recovered by LBP. The footage was viewed on twooccasions but a copy was not received.

The CCTV footage was taken from a camera positioned approximately 60 metres away from the

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bar on the corner of Springfield Place. There are no images of events in Sector 2 (DownfieldPlace) or Sector 3 (the rear of the building). The CCTV camera was moved to view the incidentat 00:59.

Whenever CCTV footage is used as a form of reference, it has been documented stating start timeof the event.

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4 Analysis of Evidence

A Approach to analysing evidenceIn line with Health & Safety Executive guidance, ‘HSG65 Successful Health and SafetyManagement’, the analysis of the safety event establishes:What happened? [Section 5B]How did it happen? [Section 5C]Why did it happen? [Section 5D] Immediate causes,

[Section 5E] Underlying causes identified by the incident,[Section 5F] Organisational underlying causes.

Throughout this section of the report, where different sources of evidence are available they appearin the following order;• Photographs (with file reference number),• CCTV Footage (with event start time, where available),• Interview (with Interview reference number and page number),• Control Room recordings (with times)• Supporting documentation (i.e. LBFRS Incident Log),• Procedures,• National guidance and information documents• Expert testing, examination and reports.

Quotes taken directly from interviews are shown in italics.Extracts from supporting documents are shown in red italics.

B What happened?Evidence from the death certificate, issued on 15th July 2009, stated that Ewan Williamson died of;(a) Severe burns plus inhalation of fire gases (awaiting investigations)(b) Building fire

A further death certificate was issued and the cause of death stated;(a) Death in Building Fire – Precise Cause Uncertain

Extensive tests have been carried out on the Personal Protective Equipment (PPE) worn by FFWilliamson, including breathing apparatus equipment.

The report on the breathing apparatus equipment is currently held by the Crown Office ProcuratorFiscal Service (COPFS) and has not been made available for the purposes of this report.

The tests carried out on FF Williamsons PPE were conducted by Health & Safety Laboratories.Again the report is currently held by COFPS and not available for this report. However a letterreceived from the Principal Inspector, Health & Safety Executive stated ‘the Personal ProtectiveEquipment worn by Fire-fighter Williamson at the time of the incident was found to be of adequatestandard’. This letter is included in Appendix 8.

These reports are included in Appendix 10 and 11.

There is also a report on tests carried out by BTTG, Fire Technology Services on FF Williamson’ssecond set of PPE, this report is included in Appendix 9.

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C How did it happen?• FF Williamson was committed in BA, to the bar for a second time,• Uncontrolled and unplanned venting of hot and combustible gases from the

basement and ground floor of the bar took place during firefighting and rescues,• Whilst exiting the building FF Williamson was separated from his BA partner and

became trapped in a toilet,• There was a significant collapse of the ground floor structure concentrated in the area

where FF Williamson was trapped,• FF Williamson was fatally exposed to fire and extreme heat.

D Why Did it Happen?Immediate causes1. FF Williamson and FF were recommitted, in BA, to the basement with

minimal recovery period between BA wears.2. Uncontrolled and unplanned venting of hot and combustible gases from the

basement and ground floor of the bar took place during firefighting and rescues.3. No water was applied to the fire.4. While exiting the building FF Williamson was separated from his BA partner and

became trapped in a toilet.5. There was a significant collapse of the ground floor structure6. FF Williamson was fatally exposed to fire and extreme heat

D1 FF Williamson and FF were recommitted, in BA, to the basement withminimal recovery period between BA wearsThere are a number of sources of evidence which confirm that FF Williamson and FF werecommitted to the bar for a second time, including LBFRS Photographs, CCTV footage andinterview transcripts from WM (Sector 1 Commander), FF (FF Williamson’s BApartner), FF (BA Team 2), and FF (Sector 1 BAECO).

D1.1 LBFRS Photograph R0011769.JPG (Appendix 4 – File 105130);This photograph shows FF Williamsons BA Tally in the BA Board, the time of entry, the calculatedToW, location of team and BA Team activity.

D1.2 CCTV footage timed at 01:16.36;This footage shows a BA team (BA Team 1) being committed to the bar from Sector 1 at 01:16.36.

D1.3 WM Personal Statement;‘FF Williamson confirmed they were going back to the basement to commence firefighting.I remember patting both Ewan and firmly on the arm and giving them the thumbs up, they bothacknowledged with a nod as they gathered the hose reel and proceeded.’

D1.4 WM Interview;‘I know the crews were back out, eh, recharging their cylinders at that stage.’

‘I remember when Ewan and were committed for a second time.’

D1.5 FF Interview;Question asked by interviewer: ‘Ok, so across at set servicing and again, I don’t know if you’ve gotmuch of an idea of how long you think you were out?’

‘Outside before going back in?… didn’t feel like a great length of time but again I would, maybe 10minutes max I would have thought.’

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‘Well we, actually I remember eh servicing sets, em obviously taking on the water and then puttingthe sets back on our back and moving back towards the area, as in the, where the entry controlpoint and the front door sort of area. And I can vaguely remember being asked if we were good togo again and it was, yeah we were fine.’

‘…being given a brief for what we would be doing and being recommitted. And the brief was, followthe line of hose into the bar area, along the bar, back to the stairs, back into the basement, ehfirefighting.’

D1.6 FF Interview;‘Ye. Eh so after we serviced our sets one of us returned to the entry control board or the entrycontrol point. Em Watch Manager was there along with entry control officer ehand Firefighters and Williamson were re-committed by Watch Manager and he toldthem to eh he told them to return to their branch in the basement and try and extinguish the firewhilst taking with them a hose reel for protection whilst en route back to the branch.’

Question asked by interviewer: ‘What sort of time’s that between you coming out and until youwere all back at the board?’

‘Between coming out would be em 10-15 minutes I would say, just guessing to be honest eh about10 minutes’

D1.7 FF Interview;‘Yip, they [referring to FF Williamson and FF had about, they had about 5 – 10 minuteturnaround.’

‘Cause I could see them, the whole time when I was doing everything they were all just off to myright hand side, the four of them, sitting chatting, drinking water, servicing their sets at the sametime.

‘2 of them.’

‘01.17… That was when they went into air… They were leaving my board at 01.17.’

‘They got their brief told to them and they knew what it was… It was identical to their first brief but itwas follow the line of hose to the bottom of the stairs and relieve and ’

D1.8 FF Interview;‘Em, so anyway come over to us, asked us if eh, if eh, are we all ok andwe’ve all gone yeah, yeah all good, em and then a short while after that eh he’s asked us if we we’reok for another wear em, again we’ve all gone yeah, no problem. Em, eh, and Ewan were readybefore and I em, so they’ve made it to the entry control point basically before and Idid em so, eh. They were recommitted…’

D1.9 Communities and Local Government (CLG) Report [extract from page 6] – CoreTemperature, Recovery and Re-deployment during a Firefighting, Search and RescueScenario, Fire Research Technical Report 18/20088

Executive summary – Recommendation (2)

‘For firefighting, search and rescue activities conducted under conditions of live fire and continuedto the operation of the low cylinder pressure warning whistle, the average firefighter should have at

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least 50 minutes of recovery, ideally, but not necessarily in a cool environment, with their PPEremoved, and to consume a minimum of 1000 ml cold water. This recovery duration should beextended to at least 65 min to protect 95% of firefighters engaged in more typical 20 mindeployments and redeployments.’

D1.10 Summary and analysis of evidence relating to FF Williamson and FF beingrecommitted in BA to the basement with minimal recovery period between BA wears.• CCTV footage showing a BA Team being committed to the bar at 01:16.36,• FF Williamson and FF were recorded on the BAECB as being recommitted at

01:17. They were the tasked to proceed to the basement and attack the fire,• They were briefed by WM to proceed to the basement and continue to fight the

fire,• LBFRS Photograph R0011769.JPG showing FF Williamson’s BA tally in BA Board.

D2 Uncontrolled and unplanned venting of hot and combustible gases from thebasement and ground floor of the bar took place during firefighting and rescues,There are several sources of evidence confirming that venting of the bar took place, including WM

(Sector 1 Commander), CM FF (Pump Operator, 301), FF (BA Team 4),FF (BA Team 2), FF (BA Team 2) and FF (Sector 1 BAECO).

D2.1 WM Interview;‘The occupier then took me round to Downfield Place to show me the hatch…’

‘Beer hatch…’

‘I think it was [who opened the beer hatch] because I’m sure he said right, oh we’lldeal with that.’

‘so that was opened… Well we wanted to see if it was, erm, if it was a possibility for access morethan anything else…’

D2.2 CM Interview;‘I spoke to told him that, that’s 512 in attendance anything at all he needed and he toldme to standby, he had a lot on his plate, because there was a lot going on around, and the first taskthat my crew were given was opening up the hatch’

‘The, the chap who was the owner of the bar, now he, he was walking about at the front and hehad come round, erm, and he told them how to get the hatch open. I thanked him, I said to himthat it wasn’t safe enough to stand there and would you mind going back, he actually came roundand showed us where the hatch was and it was quite obvious where it was… then we ushered himback oot.’

Question asked by interviewer: ‘Was there, is there any reasons given to you for opening thehatch?’

‘No.’

Question asked by interviewer: ‘So you just opened the hatch?’

‘Yes.’

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D2.3 FF Interview‘the first, first job I think we got when we got there was to open up a, a barrel hatch at the, at theside, er, down, er, Cathcart Place I believe it is… Er, Downfield Place.’

‘it was that asked us. But I think he’d taken his, his brief from the, the SectorCommander, he’d taken instruction from the Sector, Sector Commander.

‘ and went round to, er, Downfield Place you said, with the owner ofthe bar. Who, er, who was just going to basically show us where the hatch was.’

‘we just took a hooligan tool and a pinch bar, just to see if that, if that would do the trick.’

‘the barrel hatch had, er, two doors on it that were, er, on the ground. Er, with a lock in the middle ofit and they both opened up out the way.’

‘we managed to actually prise the lock open with the hooligan tool to, to burst the lock that was onit and then, and then open it up.’

‘it would have taken maybe… no more than five minutes.’

D2.4 FF Interview‘Probably only stood by there for a minute or two before came back to us and we wereasked to go round the side, em, I think primarily to open the barrel hatch.’

‘I think we were brought round primarily… with opening it, there was a wee bit of a conflab aboutthat so came back down, asked us to try and open it. Em, we had a bit of difficulty openingit. I believe if I can remember rightly, it was locked from the inside and opened basically in two halvesoutwards, opening… the way in to either side of the street. If I can remember rightly, the lock for itwas on the near side of the building up against it. At that point the owner of the bar came round theside of the building. I can’t remember whether he came round the side of the building with us initiallyor whether he just came round shortly afterwards. He identified himself to who is the owner of thebuilding, eh, I think told us where the – it may have been a padlock or whether it was just a bolt lockon it – was and I just remember that and we just managed to either break it or knock it loose inorder to get it open.’

D2.5 CM Interview;‘Basically, first request was could you get me, could you get me a couple of bodies, a coupleof personnel you know, that is free, that’s no got a task… he says I’m needing them with hooligantools, I’m needing to get the windows put in, in the front.’

‘he says well, a hooligan tool or some sort of suitable item and I’m wanting all the windows in at thefront of the building.’

‘my understanding was the fire was still burning and in theory, what he was asking me to do wasvent the premise.’

‘I distinctly remember I only done the two either side of the door… So I went back and says, I’vedone the two either side of the door, do you want me to just keep going with that? Aye, aye, I’mwanting the front all opened up. I need to, you know, improve conditions on the ground floor, so Idone the rest.’

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D2.6 FF Interview;‘for some reason I must have registered that, maybe wi speaking to that it must have beenhot in there as I say eh I probably have asked him what was happening and I says to would itno be worthwhile venting it just to gi them some comfort if they’re trying to find this hatch orwhatever…’

‘Eh and just to try and release the smoke so they could see where they were gan and saysawe… he sort of hummed and hawed aboot it and was just ken I thought maybe it’s a gid idea butthen it’s maybe no a gid idea eh then shortly after that he was asking for the hooligan tool so that

could pit in the windaes.’

D2.7 FF Interview;‘Aye, we’d been down a wee bit of time I would have thought by that and we got a radio message.I got the radio message through, I don’t know if got it because I did tell him that em, they weregoing to break the windows up the stair eh, and literally like a switch like switching a light on as soonas I’d got that message and the windows must’ve been broke the heat did rocket up.’

D2.9 FF Interview;‘ took myself and Firefighter he asked myself and Firefighter to follow himalong the street which we did and he took us to a pavement hatch which was just off Dalry Roadonto Downfield Place. Em that would be on the corner face of the building, just past… yip that wasbe it, that’s straight on… Em when we got there that hatch was open, eh there was a lot of smokecoming out of that hatch, a lot of thick black smoke coming out.’

‘When we got round there that was open and as I say I was aware of very thick black smokecoming out of there. It looked pressurised as well it wasn’t just floating out it was more coming outand again coming up the hatch and across the pavement as well.’

‘It was left open as far as I was concerned em. I was only there for a short time eh as far as I’mconcerned it was left open ye and I certainly never saw it getting closed.’

‘I witnessed Crew Manager from McDonald Road, he was then starting to break windowsat the front of the pub.’ ‘So if you’re standing looking at the main entrance to the pub, you know theentry… He was smashing the windows to the right hand side of that.’

D2.10 FF Interview;‘so we’ve gone over to the cellar delivery hatch, which had been opened. There was thick smokepouring out of that’

‘I then witnessed eh from Mac Road being ordered to smash windowswith a hooligan tool.’

‘So he’s smashed the windows on either side of the entrance.’

D2.11 FF Interview; ‘ and They were ready to be re-committed, came back to the board and tookthem round to Downfield Place before they went into air.’

‘He took them round to the corner… To check if it was feasible to make an entry into the basementthrough the cellar hatch at the pavement’

‘Because that had been opened’

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‘So eh the windows got put in…’

‘And that was purely to aide venting.’

‘Because the smoke level was top to bottom and there was zero visibility, so that was why they putthe windows in. it was nothing to with any… any kinda trying to alleviate the heat, it was all aboutvisibility.’

‘No no, they’re still not in yet, they were round looking at the hatch when the windows went in’

D2.12 Summary and analysis of evidence relating to uncontrolled and unplanned ventilation ofthe bar• WM is directed to the beer hatch by the Bar Manager and instructs a crew to

gain access to the beer hatch,• The beer hatch is left open,• WM instructs CM to break open the windows at the front of the bar to

ease conditions inside for the crews,• FF (BA Team 4) hears a message on the fireground radio that ventilation is

about to commence and very quickly ‘the heat did rocket up’.

D3 No water was applied to the fireThere are several sources of evidence relating to no water being applied to the fire, includinginterview transcripts from WM (IC/SC), FF (BA Team 1), FF (BA Team 4), FF

(BA Team 4), FF (BA Team 2) FF (BA Team 8), FF (BA Team 8)and further supplementary evidence.

D3.1 WM Interview;‘Yes, aye, they were in and it was, it was actually once they were committed, erm, and I said, wellthe conditions hadn’t changed any in that the smoke was still billowing, the fire was obviously stillburning, couldn’t, hadn’t seen a flame yet, not even a hint of a flame and the crews that had been inhadn’t seen any flame either, although they could feel that the floor was quite warm, quite hot…’

D3.2 FF Interview;‘Em, cos I remember em originally being at the bottom of the stairs, Ewan on the branch…’

‘I think in total, we advanced about 2 feet, em because at that point having pulsed water in theceiling, water coming down, no’ being able to hear anything, signs of fire. Carried out a gaugecheck at that point as well and it was decided that, that it was time to turn around.’

Comment: FF later corrects this statement and confirms that he was referring to metres,not feet.

D3.3 FF Interview;‘Well you could hear like a crackling.’

‘We could both hear a crackling but I didn’t, I didn’t ever see actual flames.’

‘I didnae see any flames, no. I says that the whole… I’ve, I’ve never actually seen a fire eh? haslocated what he’s obviously thought was the fire and well, or what was flames and was gas coolingbut from where I was I didnae see anything.’

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D3.4 FF Interview;‘Em… at that point there was no flames that I could see. It was certainly a hell of a lot hotter whenwe got in there.’

‘The branch was approximately 2 metres from beyond the door.‘

‘I picked up the branch.’

‘I can’t see flame no.’

‘It wasnae directly ahead not at this point but there was… there was no flames but when I wasfinding my bearings, there was, I did become aware of an orange glow.’

‘Which was up ahead slightly to the left em when I got doon to the branch, came doon,we’ve done a gauge check and I’m slowly trying to edge my way forward, I was listening for the fire,I could hear the crackling at first, I’d made my way beyond, what I thought was the wall was thepillar… And when I got to beyond that that’s when I became aware of an orange glow, up… itlooked like it was to the left behind a wall… That’s the only… it’s just a glow. The reason why I sayI’m sure it was to the left at the time is because the crackling seemed to be coming from furtherbehind on the left of the fire.’

D3.5 FF Interview‘I never passed on a lot of information because Ewan Williamson and they were the firefightingteam, eh, we were just assisting them and they were sort of saying that, I mean the 4 of us werethere but I was listening to what they were saying, the information they were giving was, wascorrect as in that they’d, a line of hose was in the basement, em that’s as far as they’d got, they’dleft it there, em they didn’t think the fire was extinguished, em and there really wasn’t much more topass on, other than that. To be honest, we had achieved, or they had achieved getting into thebasement, they’d achieved finding access to the basement but other than that, we hadn’t reallyachieved much from that BA wear in terms of firefighting, eh? We couldn’t confirm that, we knewthere was a fire in there, we couldn’t confirm there was a fire in there because we hadn’t seen it.Obviously we knew with the heat and everything that there was something but we hadn’t physicallymade contact with the fire or could say we’d hit the fire or not and that’s really the information thatwas passed on.’

D3.6 FF Interview‘so we’ve gone over to the cellar delivery hatch, which had been opened. There was thick smokepouring out of that.’

Question asked by interviewer: ‘When you’re saying that eh you saw thick smoke pouring out it,how would you relate that to the smoke you saw when you first turned up?’

‘I would say exactly the same, I mean it was the same… it was the same sorta density, darkness,same sorta dirtiness it was an acridy type smoke… I mean it was just blowing out, it was, it wasjust, no’ pumping out but I mean it was, it was issuing, it was smoke issuing the same sorta level asit was when I embarked eh inside.’

‘So I knew that, I knew that water was being applied… There was no, there appeared to be noprogression from point of arrival to this point now and it was no’ lessening either and I know thatthey’d sprayed water when they were in the basement.’

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D3.7 Summary and analysis of evidence for no water being applied to the fire.• FF Williamson and FF were the first crew to enter the basement to fight the

fire. They made limited progress into the basement and did not apply water to the firebut did spray water within the basement area,

• The second team to enter the basement (FF and FF also made limitedprogress in the basement and penetrated about 3 metres from the bottom of thestairs. They also did not apply water to the fire but did spray water within thebasement area,

• From the time of first call to the Fire Service Control Room at 00:38:38 and 01:17 (thetime FF Williamson and FF re-entered the bar for the second time) the firewas continuing to develop. For 39 minutes, conditions within the basement continuedto deteriorate,

• During the period from the first attendance there was no reduction in the amount ofsmoke that was coming from the bar. CCTV footage shows significant increases insmoke issuing from the bar throughout the incident.

D4 While exiting the building FF Williamson was separated from his BA partner andbecame trapped in a toiletThere are several sources of evidence confirming that FF Williamson was separated from his BApartner whilst exiting the bar, including interview transcripts from FF (FF Williamson’s BApartner), FF (BA Team 2), FF (BA Team 2), WM (Sector 1 Commander), FF (Sector 1 BAECO), FF (Pump Operator, 301), LBFRS Control Room Transcripts and IncidentLog.

D4.1 FF Interview;‘I lead us out… I remember coming back up the stairs. I remember saying to Ewan ‘right, I’ve gotmy hands on the line of hose. We’ll follow the line of hose out’. It was like, he agreed with that, hesaid ‘right, aye’. So that was us, we’re making our way up the stairs.’

‘…he’s right behind me, the whole way, coming up the stairs. He’s right behind me.’

‘Everything seemed fine, we were heading out. Coming right along the bar, found the hatch, obviouslythe line of hose is in the corner. I remember coming off the bar, still with the line of hose and thencoming out. As far as I was, I mean I was, as far as, I’ve now come out thinking Ewan’s obviously rightbehind me. Come out and it was, I just, not long, just popped straight out and came overand he was, I don’t know what he was going to say to me but he then was like ‘where’s Ewan?’

D4.2 FF Interview;‘Okay… so passed me. Just as had left there was somebody very close behind him, I put myhand out to feel for them, I couldn’t see them and I says “is that you Ewan” and he says “aye it’s me

I says “what’s happening” and his answer was “I’m going outside I’m fucked with the heat”.Now he never stopped to say this he said this whilst continuing to move past me.’

‘He’s going outside and he’s… his words were that he was fucked with the heat he was goingoutside… his exact words but he never stopped to say it whereas maybe he briefly paused verybriefly but Ewan was like… he wasnae wanting to stay there and pass any information onto me.’

‘No sign of panic [referring to FF had enough I’m getting out aye eh and whereas Ewanwas coming and I remember looking back and can now remember being slightly concerned thinkinghe was… he was really wanting to get out. was keen to get out, Ewan, it felt to me, he was reallywanting to get out.’

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D4.3 FF Interview;‘they came past eh, and I mind was first I think, sorta patting going c’mon then guys welldone eh, and the Euan came past and I was like alright big man ken well done that sorta thing. Theycome past us on the hose, come past me, come eh come past me and thenEwan’s come past me.’

‘No, when I say I hear them that’s not on a radio message that’s me hearing them shouting to eachother because they’ve obviously, they cannae see each other so they’re shouting to each other andI’ve heard that from the top of the stairs.’

‘we’ve then moved round eh I’m dragging and feeding reel, slightly ahead of me em, by thetime we’ve made it to sorta the top of the bar area here em just at the top of the stairs at the end ofthe bar em I’ve heard Ewan and say we’re gonna have to get out it’s too hot, we’re gonna haveto get out.’

D4.4 WM Interview;‘ is immediately kind of out of the door there and he instinctively starts taking his mask off, and Iremember saying to him, and he’s, he’s hot and bothered at this stage right, which was fine, he wasjust himself, where is Ewan, oh he’s just behind me, just behind me.

‘… I went on the radio then to Ewan, erm, what’s your location, erm, still standing theregetting a breather, erm, and that’s when he came back and said right what was it… it was reallycalm and a kind of, and an easy going message I’ll be there in a min… something along the… I’ll bethere in a minute boss, I think I’m stuck in a toilet. So I thought fine, so from the state of hismessage and that I thought well he’s just in the door. I said to would you just stick your headback in the door and just see where he is, right okay. Erm, still, so he’s still no… I’m still waiting forhim to surface any second and he hasn’t…’

D4.5 FF Interview;[In the following extract, FF refers to FF Williamson as ‘Two’]

‘Yes, that was almost immediately afterwards. After the wee conflab at the door with and

‘ got on the radio and tried to get in touch with “Two”… he got straight back to him saying “I’min a cupboard or I’m in a toilet I’m a wee bit stuck I’ll be out the now”’

‘ turned round to follow the hose line back to where he thought “Two” should have been just acouple of yards behind him and then the pair of them come out together but that never happened’

D4.6 FF Interview;‘I can remember at one point turning round and was standing in the doorway to the shop,himself. Eh, which I thought was quite strange but I never really thought anything, I just, I didn’trealise Ewan was missing at that time.’

D4.7 Control Room recordings;01:34:27

325: 325 over

Control: 325 go ahead over.

325: Hello from Incident Commander, this is a BA emergency, 325 over.

2 6

1

2

3

44

Ff 5

FF 5

FF 5

FF 5

WM 1

WM 1

FF 5 FF 5

FF 5

FF 5 FF 1 FF 5

FF 1

FF 5

FF 5

Control (off radio): There’s a BA emergency. A BA emergency.

Control: 325 roger, confirm you require another ambulance to attend over?

325: Hello standby 325 over.

Control: Roger out

D4.8 LBFRS Incident Log 10161; (Appendix 12)The following extract shows;

Time, source for input (R = Radio), operator initials and the message.

0134 R 325: THIS IS A BA EMERGENCY

D4.9 Summary and analysis of evidence relating to FF Williamson becoming separated fromhis BA partner and getting trapped in a toilet:• FF and FF Williamson passed FF and FF behind the bar, FF

leading the way out;• FF and FF Williamson had been exposed to extreme heat. FF “I says “is

that you Ewan” and he says “aye it’s me I says “what’s happening” and his answer was“I’m going outside I’m fucked with the heat”.

• FF exits the bar alone (approximately 01:29);• Radio messages between FF Williamson and WM • Radio message between FF Williamson and FF FF Williamson said ‘I’ve turned

left at the end of the bar instead of right…’;• WM instructs FF Williamson to activate his ADSU;• BA Emergency is declared on main scheme radio.

D5 There was a significant collapse of the ground floor structureThere are several sources of evidence confirming that the ground floor suffered a major structuralcollapse, including CCTV Footage, FF (BA Emergency Team 1), FF (BAEmergency Team 1), FF (BA Emergency Team 2), FF (BA Emergency Team 2) and FF

(BA Team 3).

D5.1 CCTV footage timed at 01:45.31This footage shows a major increase in smoke coming from the bar. This is presumed to have beeninstigated from a significant event within the bar and coincides with the following reports from BAcrews within the bar.

D5.2 FF Interview;‘ was moving forward along the hose, I was to his right hand side, I was checking the floorand… on the right hand side just in case it eh… I didnae want to miss anything’

‘I moved to the right hand side of “As I checked the floor in front of me… my right as wemoved forward, it became clear it was not safe structurally and I had the sensation of the floor fallingaway towards my right hand side”. So when I went in there and I was to the right of who wasfollowing the hose along the side of the bar I could feel the floor was sloping away from me everytime I moved forward.’

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3

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FF 1

10

13

FF 13

FF 13

FF 13

20

20

‘It wasnae moving but you could… you had the sensation when you’ve moved forward with yourleft foot, when you moved your right foot forward it was taking me longer to get your foot down andyou could feel yourself moving to the right’

‘Every step I took. As soon as I went out to the right, to right and I moved these chairs outthe road, moved forward, every step I took I could feel the floor going away and the further I movedin it felt the floor was getting more pronounced a slope away from me.’

‘So I was in behind him, I felt the bar and the hose was at our feet. I stopped and eh I told about the state of the floor and moved back in and I told him the floor was very unstable on the righthand side but when we’ve moved in together the floor was much more stable, we were okay.’

‘Eh as we got to the hatch told me at the hatch… we had stopped just then, we were aboutto move forward, a second BA team came up behind us eh I turned towards them and madecontact and found out it was FF from Tollcross Green, I made myself know to him and Iimmediately told him about the unstable floor.’

‘Eh, we proceeded forward and eh… together and it became clear almost immediately, we tookanother couple of steps but we could go no further because the floor became that unstable.’

‘…just before that had said he had got a door on the left hand side, he had reached a door…Which now I can see is the ladies toilets’

‘Just about immediately the floor started to give way… underneath us.’

‘It actually started to collapse and I shouted right away… I screamed right away “this floor is going”and I turned back to

‘I immediately turned to and sort of pushed back the way…’

‘Over… back here towards the door and towards the bandit, sort of turned like that to push himback the way.’

‘Just seconds after that you heard it, you heard it.’

‘Ye and that’s the first time I saw flames when the collapse.’

‘Well it wasnae firm where I was but I moved as soon as I felt it starting to go and I shouted “thisfloors away” I pushed myself right in beside

‘I heard a cracking noise and then flames shot over our heads and I heard… that’s when the noiseof which was the floor collapsing.’

‘It was a whole… it was a sheet, I would put it down as a sheet of flames that had come rolling overthe ceiling.’

‘We started moving… well quickly.’

‘…we moved back as quick as we could and we sort of got ourselves composed, got our bearingsand then we started to move out.’

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3

FF 13

FF 13

FF 13

FF 13

FF 13 FF 13

FF 13

FF 13

D5.3 FF Interview; ‘But again, obviously I’m looking in… I’m noo here… The ladies toilet.’

‘Cause I felt door going… swinging open… And it was at that point says to me the floors…he can feel the floor, I says what do… he says… he was shouting like obviously… the fucking flare,this flare’s going.’

‘it swung and as it swung open I’ve sort of went to go forward and I was more or less there at thesame time that mentioned the floor.’

He says the floor’s starting to go so I’m like… again I dinnae ken how far to go in, if I’d heard theDSU I might have made a different decision like you know… keep going or but then your thinkinyour aine safety you thinking… fucking no this is really, really… This is serious shit now like, ken I’mthinking my aine… my aine…’

‘I’m wanting to go through this door and basically tried to follow me through the door andthat’s when he says I can feel the floor going... and I’m saying what… he says the floors fuckinggoing, I was thinking this floor.’

‘Heard a lot of shouting and a lot of… you know and it seemed to take an eternity to come oot.

‘and as we were coming there, that’s when we started getting blootered with the jets of water anaw.’

D5.4 FF Interview; ‘we were advancing I mean, we were advancing cautiously but quickly… we weren’t just wanderingstraight in eh we were sort of you know as you’re trained to do eh we were sort of moving slowly,advancing slowly. I think we must have got past the fruit machines and somebody’s shouted thefloors going.’

‘Or “watch out the floors going”’

‘…before that was shouted, says “I’ve got a door, I’ve got a door” now I think he must havebeen, he must have out just slightly in front of me but he was still in contact.’

‘Still on my right hand side. He said “we’ve got a door” he had a door, he was shouting on Ewan, hewas shouting "Ewan, Ewan” I was shouting “Ewan, Ewan”. At that point, I think it was either or

they shouted “watch out the floors going, the floors going”. Em I never felt anything at thatpoint.’

‘one of the other BA guys they says “watch out the floors going, the floors going”, maybe within 2-3seconds after that I felt the… I felt myself sinking through the floor.’

‘I felt, it was like a carpet going into a big hole if you like.’

‘… if you can imagine a carpet over a hole, you’re standing on it and the carpets slowly sinking intothat hole… at that point shouted “I’ve gone through, I’ve gone through” em so I put my handout and I could just sort of feel him may… I don’t know what part of his body I could feel but I couldalso feel something on my leg.’

‘I felt something on the wall that was taking my weight. I could sort of feel climbingup my leg but at the same time I was sinking in so I was having to try and step back, got onto a bitof solid ground again, felt like I had solid floor underfoot and that started sinking in again.’

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FF 3

FF 3

FF 3 FF 3

CM 4

13

FF 13

Ff 20

CM 4

CM 4

‘at that point the floor was sinking so it was like you were stepping back and you were standing onthe ground, it was solid for a second and then it was sinking. So I can remember sort of bouncingbackwards… Coming back towards the door.’

D5.5 FF Interview;‘I felt, the floor dipped slightly beneath my foot, like sagged very slightly… I’ve then heard

shout the floor’s gonna go, I’m sure that’s what he said, the floor’s, the floor’sgonna go…’

‘So I’m shoving, screaming, it’s sagged. I could hear and moving behind I could hearthem shouting as well, we’re all shouting on Ewan, floor’s gonnae go and as he said that I thoughtcome on and I shoved really hard… one more time, felt it give and then as it gave it was like a trapdoor opened below me, it was, I just dropped straight through.’

‘and there’s was just flames just pppfffffffff burst up round me. It’s the only time I seen flames allnight. I screamed, threw my arms out and my left hand hit leg and I just grabbed. He sayshe felt me pulling him…’

‘Totally disorientated, the whole floor well I’ve put it felt like a hot, wet sponge. The whole thing wasjust, it felt like it was rolling undulating constantly.’

‘…pulled myself up body eh, I says, I says we’ve gotta get outta here now I says this wholefloor’s gonnae go or words to that effect.’

‘…he’s grabbed something, I’ve then pulled myself up, out, up leg.’

D5.6 FF Interview;‘I was aware that there’d been some kind of collapse. But I don't know where I got that from. That’sone of the ones that’s kind of confused me. I was kind of aware that we were having to be cautiousbecause of the floor, but I don't know why.’

‘It felt all right… it felt pretty stable at that point.’

‘the decision I made to come back out was because I heard things starting to go round about us,and again…’

‘I kind of felt that it had been collapsing over to… in front of me to the left. I thought I heardsomething pretty heavy coming down, maybe the ceiling coming down. That was the feeling I got.But no visibility.’

‘I felt it was in front of me to the left. I heard something pretty solid coming down. And wi’ hindsight,and seeing the bar, it might well have been the bar going through the floor… I was facing towardsthe rear of the bar.’

‘I knocked off maybe two or three times. I thought I heard voice. There was so muchnoise going on, I was pretty sure I heard I thought I could hear him ahead of me…When we heard the thumping it was time to get out.’

D5.7 Summary and analysis of evidence relating to structural collapse within the bar:• FF (BA Emergency Team 1) shouts out that the floor was about to collapse

(approximately 01:45);• FF (BA Emergency Team 2) falls through the floor and is engulfed in flames;

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3

FF 3FF 3

10

FF 13

20

Ff 20

Ff 20

FF 1

FF 1

FF 1

• Major increase in volume of smoke visible on CCTV images;• No water applied to the fire;• Fire continued to develop.

D6 FF Williamson was fatally exposed to fire and extreme heat The only source of evidence is FF Williamson’s death certificates. There are two certificates; the firstone was obtained on 15th July 2009, the second on 23rd September 2010.

D6.1 Summary and analysis of evidence relating to FF Williamson being fatally exposed to fireand extreme heat:• Death certificate states ‘Severe burns plus inhalation of fire gases (awaiting

investigations)’ and ‘Building fire’;• The second death certificate states ‘Death in Building Fire – Precise Cause Uncertain’.

E Why Did it Happen?Underlying causes identified by the investigation

E1 Underlying causes identified by the investigation1. Insufficient understanding of the types of emergency and the expected outcomes;

2. Insufficient understanding of the effects of recommitting BA Teams to the bar withminimal rest period between BA wears, which led to an insufficient assessment of therisk;

3. Insufficient understanding of effects of venting the fire;

4. Ineffective briefing and debriefing of BA Teams to pass information about the accessto the basement, conditions within the bar and the floor collapse, which led to aninsufficient assessment of the risk;

5. The means of escape for BA Emergency Teams and successive basement firefightingcrews was not effectively maintained;

6. Ineffective cordons and control of the incident ground outside the bar.

E1.1 ConsequencesFrom the time of arrival, the fire was never under control or likely to be extinguished:• Control room staff failed to pass on vital information and did not seek further information of the

incident. Initial resources mobilised were not suitable for the types of emergency at this incident;• Incident Commanders failed to understand that they were facing two types of emergency. this

failure led to implementation of tactical plans that were not effective or safe. The types ofemergency at this incident were:– A fire in a basement, and;– Multiple rescues from houses with multiple occupation of persons suffering smoke

inhalation; • Rendezvous point, marshalling area, safe and hazard zones needed for effective control of

resources and the public were not established; • Incident Commanders were set to fail. They could not gain and maintain adequate control of the

incident;• The crews experienced difficulty accessing the basement and locating the main seat of fire;

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• No water was applied to the fire;• The fire was fed by uncontrolled and unplanned ventilation of the basement and ground floor;• The same crews continued to be committed to what should have been recognised as extreme

conditions;• Safe access and egress to the basement was not secured, or maintained during the incident;• Insufficient briefing and debriefing of BA Teams.

E2 The issues identified are grouped into areas of underlying cause

E2.1 Insufficient understanding of the types of emergency and the expected outcomesControl room staff failed to pass on vital information and did not seek further information of theincident. Further questioning of callers may have established that a basement fire was involved.

Control room staff failed to pass on that cylinders may be involved in the fire.

Resources mobilised were not suitable for the types of emergency at this incident. Failure toestablish the types of emergency faced at this incident and insufficient understanding of theexpected outcomes meant that resources sent were not suitable or sufficient.

Incident Commanders failed to understand that they were facing two types of emergency and theexpected outcomes required from both types of incident. This failure led to implementation oftactical plans that were not effective or safe. The types of emergency at this incident were:• A fire in a basement, and;• Multiple rescues from houses with multiple occupation of persons, from property affected by

smoke

Detailed sources of evidence listed in section E3

E2.2 Insufficient understanding of the effects of re-committing BA Teams into the bar withminimal rest period between BA wears, which led to an insufficient assessment of therisk.BA Teams are re-committed into the bar and basement with 10 minute turn around,

No control was in place to ensure that BA wearers were given sufficient rest and cooling downperiods.

Lack of rotation of available firefighters at the incident.

Detailed sources of evidence listed in section E4.

E2.3 Insufficient understanding of effects of venting the fire The opening of the beer delivery hatch as a means of access to the basement

The bar windows were broken to ease conditions inside the bar

Water was not applied to the fire and the fire was not located


3 2

E2.4 Ineffective briefing and debriefing of BA Teams to pass information about the access tothe basement, conditions within the building and the floor collapse, which led to aninsufficient assessment of the risk.Briefs were not effectively communicated to BA Teams,

The Incident Commander and Sector Commander failed to recognise the risks when committingBA Teams to the bar,

Information from crews about the floor collapse, the fire conditions and the access to the basementwas not effectively requested, or acted on, by the IC or SC,


E2.5 The means of escape for BA Emergency Teams and successive basementfirefighting crews was not effectively maintained.BA Emergency teams were committed to the bar without any means of firefighting

BA Teams gained access to, and from, the basement without any means of firefighting and usedbranches already in the basement area

The emergency exit leading into the common stair at No.1 Downfield Place was not identified duringthe incident


E2.6 Ineffective cordons and control of the incident ground outside the bar

Rendezvous point, marshalling area, safe and hazard zones needed for effective control ofresources and the public were not established

Incident Commanders were set to fail. They could not gain and maintain adequate control of the incident

BA wearers gathering in Sector 1 around the BAECB


E3 Insufficient understanding of the types of emergency and the expected outcomesThere are several sources of evidence relating to insufficient understanding of the types ofemergency and expected outcomes, including LBFRS Control Room transcripts, Incident log andService Improvement Plan 2005-2010.

E3.1 Control Room recordings00:38:38

Control: Fire and Rescue

Caller: Fire Brigade please, eh, Dalry Balmoral Pub at Dalry Road please

Control: The Balmoral Pub?

Caller: Yeah at Dalry Road

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Control: What’s the problem?

Caller: Fire

Control: What’s on fire?

Caller: The pub

Control: Right, so the pub’s on fire?

Caller: Yeah. Emergency.

Control: We’ll get the...

Caller: Quickly.

Control: Are you telling the truth?

Caller: I’m telling the truth. Trust me. It’s on fire.

Control: Right ok. We’ll have the Fire Service attend ok.

Caller: Sorry?

Control: We’ll have the Fire Service attend.

Caller: Right

Control: Ok?

Caller: Well you need to be quick, really. It’s on fire.

Control: Right. Ok?

Caller: Right cheers

Control: Right thanks

Caller: Bye

00:41:16

Control: Hiya Police.

Police Control: Hi Fire. Are you aware of a fire in the Balmoral Bar, in Dalry Road in Edinburgh?

Control: We are. Somebody phoned but I dinnae ken if I believe them or no.

Police Control: Well it was a no response 999 and I spoke to the bar staff and they are pretty em,upset and they are saying that, em, there’s gas cylinders and everything inside and the place is upin flames.

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E3.2 LBFRS Control Room recordings00:49:43

Control: Fire and Rescue

Woman’s voice ‘aye, I was quite concerned...’

Caller: Hello, hello there’s a fire at, em, Downfield Place the pub the Balmoral.

Control: Is it the Balmoral Pub at Dalry Place?

Caller to someone else: Do you know what’s happening?

Control: Hello is that Dalry Place please?

Caller: Are they? Ok (said to someone else).

Control: Dalry Road

Caller: Ok. Hello?

Control: Is that on Dalry Road?

Caller: Yes

Control: Sir and it’s the Balmoral Pub?

Caller: Yeah, it’s on fire and the Fire Brigade are here but I’m stuck above and I’m...

Control: You’re in a flat above?

Caller: Yep

Control: Right what flat are you in?

Caller: I’m 1F eh one, two sorry.

Control: You’re probably safer staying inside your flat sir. We’ll let the crews know that you’re thereok?

Caller: Right ok.

Control: Just keep the doors and windows shut you’ll be safer probably in your flat. If they wantyou to evacuate, they’ll come and get you, ok?

Caller: Keep them shut?

Control: Yeah, just keep your doors and windows closed, ok? If you’ve got any smoke coming injust put something along the bottom of the doors.

Caller: Well there’s quite a lot of smoke coming in here

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Control: Yeah if you put something along the bottoms of the doors what we’ll do is let the firecrews know that you are in the flats above

Caller: Right, ok

Control: In 1F2, ok? We’ll let them know you’re there sir. Ok? Bye.

E3.3 Incident Log (Appendix 12)The following extract shows;

Time, source for input (O = Operator,

R = Radio), Operator initials, message

0055 O 301 INFORMED OF RESIDENTS* WITHIN FLATS ABOVE HAVING

SMOKE ENTERING THEIRPREMISES

0055 R 301:MAKE PUMPS 5* Make pumps 05

E3.4 Mobilisation message to station (Appendix 24)The following is the only mobilisation that was recovered from the incident. It was not possible forthe investigation to get duplicate copies of all the mobilisation messages for the duration of theincident.

This mobilisation message was for 512 and was sent after ‘Make pumps 4’.

To Attend: 512, 364, 325, 544Address:BALMORAL PUBDALRY ROADEDINBURGHStation Area: 30 Map Ref: NT235724Type: BUILDING ALIGHTSpecial Risks:Add Info:Inc No: 10161, 12. JUL. 09 @ 0051Orig. Tel.No: Further Info:Make Pumps 04Station Message:Fireworks Stored At LidlStation Message:Fireworks Stored At LidlDalry RoadResources already assigned:301, 302, 303, 311, 564.

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Phone No. Removed

E3.5 Service Improvement Plan 2005-2010 (Appendix 25)

Structural firefightingWe respond to any call to a fire in a building or any other land-based structure.

We will respond immediately to any request for assistance.

We will attend any call to a fire within a building or any other land-based structure within a timeconsistent with our existing targets.1

We will mobilise a fully capable team to each incident.2

This will be subject to internal audit and be reported on quarterly.

1 The 1985 standards of fire cover have been revoked. Further details on these standards can befound in ‘The CFBAC Report of the Joint Committee on Standards of Fire Cover’. We intend toprovide a response to structural fires with time targets which are consistent with the existing firstresponse times. Subsequently, any variations will be based on an evidence-based argument.

2 Our definition of a ‘fully capable team’ will depend on the type of incident we are attending.Amongst other things, this will mean that we will mobilise two fully crewed appliances to all fires inbuildings (where the 1985 standards of fire cover called for only one) and three appliances to a firewhere persons are believed to be involved (where the 1985 standards may have called for one ortwo appliances).

E3.6 Summary and analysis of evidence relating to insufficient understanding of the types ofemergency and the expected outcomes• Control room staff failed to pass on vital information and did not seek further information of the

incident from the initial callers. Resources mobilised were not suitable for the types ofemergency at this incident.

• Control room staff failed to pass on that cylinders may be involved in the fire. Furtherquestioning of callers may have established that a basement fire was involved and that rescueswere required from the flats above.

• Failure to establish the types of emergency faced at this incident and insufficient understandingof the expected outcomes meant that resources sent were not suitable or sufficient. ControlStaff and Incident Commanders failed to understand that they were facing two types ofemergency and the expected outcomes required from both types of incident.

• Expected outcomes from incidents not defined in SIP 2005-2010.

E4 Insufficient understanding of the effects of recommitting BA Teams to the barwith minimal rest period between BA wears, which led to an insufficientassessment of the risk.There are several sources of evidence relating to BA wearers being recommitted with minimal recoveryperiod, including photographs, CCTV Footage, interview transcripts from WM (IC/SC1), FF

(BA Team 1), FF (BA Team 2), FF (BA Team 2) and FF (BAECO).

E4.1 LBFRS Photograph R0011769.JPG (Appendix 3);This photograph shows FF Williamsons BA Tally in the BA Board, the time of entry, the calculatedToW, location of team and BA Team activity.

Comment: This is the only recorded BA entry for the whole incident. It does not show this as beinga second entry for FF Williamson but confirms he was committed at 01:17.

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11 3 45

E4.2 CCTV Footage timed at 01:07;This footage shows four BA Wearers exiting the bar. The four BA wearers committed to the bar atthis time are FF Williamson and (BA Team 1) FF and (BA Team 2).

Comment: It is not possible to identify the firefighters in this footage but it is assumed that it showsBA Teams 1 and 2 exiting the bar.

E4.3 CCTV footage timed at 01:16.36;This footage shows a BA team (BA Team 1) being committed to the bar from Sector 1 at 01:16.36.

Comment: This footage is further evidence of a BA Team being committed at 01:17. It is notpossible to identify either firefighter in this footage.

E4.4 WM Statement;‘The BA crews Teams 1 & 2 re-emerged from the building as cylinder pressure was getting low.They were all hot/steaming and dirty however they confirmed they had located the basement…’

‘Team 1 were keen to be re-committed… FF Williamson confirmed they were going back to thebasement to commence firefighting. I remember patting both Ewan and firmly on the arm andgiving them the thumbs up, they both acknowledged with a nod as they gathered the hose reel andproceeded.’

E4.5 FF Interview;‘Well we, actually I remember eh servicing sets, em obviously taking on the water and then puttingthe sets back on our back and moving back towards the area, as in the, where the entry controlpoint and the front door sort of area. And I can vaguely remember being asked if we were good togo again and it was, yeah we were fine.

Question asked by interviewer: ‘Ok, so across at set servicing and again, I don’t know if you’ve gotmuch of an idea of how long you think you were out?’

‘Outside before going back in? Em, again no. Em, didn’t feel like a great length of time but again Iwould, maybe 10 minutes max I would have thought. But again, that’s, that’s just a guess, I mean I,I’ve not got any idea of time at that point.’

E4.6 FF Interview;‘Ye. Eh so after we serviced our sets one of us returned to the entry control board or the entrycontrol point. Em Watch Manager was there along with entry control officer ehand Firefighters and Williamson were re-committed by Watch Manager

Question asked by interviewer: ‘What sort of time’s that between you coming out and until youwere all back at the board?’

‘Between coming out would be em 10-15 minutes I would say, just guessing to be honest eh about10 minutes’

‘Aye, I would agree, I would agree with that... 10-15 minutes whilst exiting from the first wear em’

‘... we all went back to the entry control board and they were re-committed em pretty muchimmediately on their return to the entry control board.’

‘The four of us went over ye em assuming that we were going in…’

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E4.7 FF Interview;‘Em, so anyway Station Officer come over to us, asked us if eh, if eh, are we all ok andwe’ve all gone yeah, yeah all good, em and then a short while after that eh he’s asked us if we we’reok for another wear em, again we’ve all gone yeah, no problem. Em, eh, and Ewan were readybefore and I em, so they’ve made it to the entry control point basically before and Idid em so, eh. They were recommitted…’

E4.8 FF Interview;‘Yip, they had about, they had about 5 – 10 minute turnaround… Cause I could see them, thewhole time when I was doing everything they were all just off to my right hand side, the four of them,sitting chatting, drinking water, servicing their sets at the same time.’

‘2 of them.’ [Referring to FF Williamson and FF

‘01.17… That was when they went into air… They were leaving my board at 01.17.’

E4.9 LBFRS Framework Operational Procedure 3.1 [extract page 5] (Appendix 13)Environmental conditions

Heat and humidity

Working in hot and humid atmospheres can lead to serious physical effects including rapid fatigueand confusion. In consequence, performance levels deteriorate, decision making and manipulativeskills reduce and vision is adversely affected. In order to reduce the risks involved fireground controlmeasures will include:-• Keeping personnel cool and relaxed prior to deployment• Limiting exposure• Working at low rates of effort• Taking breaks where possible• Drinking water

Individuals should be aware of the signs of heat stress and be able to recognise the onset ofsymptoms. Personnel who indicate or show signs that they are suffering from heat stress i.e.experiencing dizziness, nausea, abdominal pain, or a burning sensation of the skin, should bewithdrawn to fresh air. Fluid is available for all personnel involved to replace body fluids and preventdehydration.

For further more detailed information refer to the SIFTC leaflet on heat stress.

E4.10 Communities and Local Government (CLG) Report [extract from page 6] – CoreTemperature, Recovery and Re-deployment during a Firefighting, Search and RescueScenario, Fire Research Technical Report 18/2008Executive summary – Recommendation (2)

‘For firefighting, search and rescue activities conducted under conditions of live fire and continuedto the operation of the low cylinder pressure warning whistle, the average firefighter should have atleast 50 minutes of recovery, ideally, but not necessarily in a cool environment, with their PPEremoved, and to consume a minimum of 1000 ml cold water. This recovery duration should beextended to at least 65 min to protect 95% of firefighters engaged in more typical 20 mindeployments and redeployments.’

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WM 1

E4.11 Fire Service Manual, Volume 4, Fire Service Training, Guidance and ComplianceFramework for Compartment Fire Behaviour Training (CFBT)9

Section 8.6 Physiological Controls, paragraph 8.6.9

Risk control measures to prevent harm being caused can be conveniently divided as follows:

Pre-Exposure Control Measures

• Health Monitoring and Self-Assessment

Prior to any period of training involving exposure to hot conditions, firefighters should be subjectto a form of health check, usually involving a self-completed checklist or questionnairedeveloped and agreed in conjunction with the Brigade's Medical Adviser.

• Information and Training

Firefighters must be given adequate information and training not just in recognising thesymptoms of heat related illness but also in understanding how their susceptibility might varyand the factors that can contribute to that variation. “The Heat is On” document used by anumber of brigades provides a useful reminder to trainers and students of the various risks andpersonal factors that may have an impact on their well being.

• Health Monitoring

Records of exposures to CFBT environments should be maintained for all instructors andstudents and any other persons entering the training compartment during training scenarios.

Comment: This document provides guidance to Chief Fire Officers/Firemasters and BrigadeTraining Officers/training providers in the safe and effective delivery of compartment fire behaviourtraining (CFBT). It provides step by step guide to the process of ensuring that CFBT properlyaddresses identified training needs and delivers appropriate training with due regard to the safety oftrainees, trainers and others involved in training delivery.

E4.12 Summary and analysis of evidence relating to BA wearers being committed into bar withminimal time to recover:• The BA wearers (FF Williamson and FF and were all

recommitted to the bar and briefed to proceed to the fire compartment. The timebetween both teams exiting the bar and the re-entry for FF Williamson wasapproximately 10 minutes;

• No consideration to using firefighters who had not previously been committed in BAat the incident;

• The CLG report ‘Core Temperature, Recovery and Re-deployment during aFirefighting, Search and Rescue Scenario, Fire Research Technical Report 18/2008’gives guidance on the minimum recovery periods required to protect firefightersduring BA deployments;

• Guidance is supplied to FRS in the form of ‘Fire Service Manual, Volume 4, FireService Training, Guidance and Compliance Framework for Compartment FireBehaviour Training’. This guidance is specifically targeted to the training environment;

• There is currently no national guidance on the recovery rate and redeployment of BAwearers at operational incidents. As a result no operational guidance is given tofirefighting personnel within LBFRS.

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E5 Insufficient understanding of effects of venting the fireThere are several sources of evidence relating to venting the fire, including CCTV footage, interviewtranscripts from WM (IC/SC), CM FF (Driver 301), FF (BA Team 4), FF

(BA Team 4), FF (BA Team 2), FF (BA Team 2), FF (BAECO) and nationalguidance to the Fire Service.

E5.1 CCTV Footage timed at 01:20;The CCTV footage shows 1 firefighter at the front of the bar breaking the windows. In this footagethere is no indication that a covering jet is being used.

E5.2 WM Interview;‘The occupier then took me round to Downfield Place to show me the hatch… Beer hatch…’

‘I think it was [who opened the beer hatch] because I’m sure he said right, oh we’lldeal with that.’

‘so that was opened… Well we wanted to see if it was, erm, if it was a possibility for access morethan anything else…’

Question asked by interviewer: ‘Had you asked for a covering jet to be put…’

‘Into that?’

Question asked by interviewer: ‘Well first of all to initially cover the, erm, the hatch being opened?’

‘No I hadn’t no. It was just a straightforward case of kind of opening it.’

E5.3 CM Interview; ‘Basically, first request was could you get me, could you get me a couple of bodies, a coupleof personnel you know, that is free, that’s no got a task… he says I’m needing them with hooligantools, I’m needing to get the windows put in, in the front.’

‘he says well, a hooligan tool or some sort of suitable item and I’m wanting all the windows in at thefront of the building.’

‘I’m wanting all the windows in at the front of the building…’

‘I remember him saying I need to improve conditions for the crews on the ground floor.’

‘my understanding was the fire was still burning and in theory, what he was asking me to do wasvent the premise.’

‘I distinctly remember I only done the two either side of the door… So I went back and says, I’ve donethe two either side of the door, do you want me to just keep going with that? Aye, aye, I’m wanting thefront all opened up. I need to, you know, improve conditions on the ground floor, so I done the rest.’

Question asked by interviewer: ‘Do you know if, when, when you were breaking the windows ifthere were, if there were any hose reels or jets available directly outside?’

‘Er. I don’t know nut, nut. I know that later on, later on there was a jet there and a jet going in thewindow but that was like after the windows had been put in. So I don’t know what there was at thetime. As I say there was limited resources and personnel there, so I wouldn’t …don’t know.’

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E5.4 FF Interview;‘for some reason I must have registered that, maybe wi speaking to that it must have beenhot in there as I say eh I probably have asked him what was happening and I says to would itno be worthwhile venting it just to gi them some comfort if they’re trying to find this hatch orwhatever…’

‘Eh and just to try and release the smoke so they could see where they were gan and saysawe… he sort of hummed and hawed aboot it and was just ken I thought maybe it’s a gid idea butthen it’s maybe no a gid idea eh then shortly after that he was asking for the hooligan tool so that

could pit in the windaes.’

‘I can remember when it actually happened that Ewan and were in the building because I canremember sending the message to them to make sure they were on a branch because wewere gonna pit the windaes in eh and let us know when they were on the branch sort of thing eh sothey had protection… I can remember him sending it to Ewan and eh

‘Eh cause they were, they must have been the only team in at the time… when they vented.’

‘ specifically said to Ewan and aboot, being on, make sure you’re on a branch.’

‘There was bodies milling aboot, because obviously they were all made aware that the windowswere going to be smashed and there was a jet, a covering jet set up as well before it was done.’

‘Yes. It was taken from my pump because I grabbed the stuff and set that up as well. I’m sure thatI got another length of flaked hose oot the pump bay again.’

‘Aye just aboot sort of, a covering jet just to the back of my pump so it was sitting on the pavementjust ready to go. I couldnae tell you who was on it, but there was somebody on it… Just one…’

E5.5 FF Interview;‘Aye, we’d been down a wee bit of time I would have thought by that and we got a radio message.I got the radio message through, I don’t know if got it because I did tell him that em, they weregoing to break the windows up the stair eh, and literally like a switch like switching a light on as soonas I’d got that message and the windows must’ve been broke the heat did rocket up.’

E5.6 FF Interview; ‘ took myself and Firefighter he asked myself and Firefighter to follow himalong the street which we did and he took us to a pavement hatch which was just off Dalry Roadonto Downfield Place. Em that would be on the corner face of the building, just past… yip that wasbe it, that’s straight on… Em when we got there that hatch was open, eh there was a lot of smokecoming out of that hatch, a lot of thick black smoke coming out.’

‘When we got round there that was open and as I say I was aware of very thick black smokecoming out of there. It looked pressurised as well it wasn’t just floating out it was more coming outand again coming up the hatch and across the pavement as well.’

‘It was left open as far as I was concerned em. I was only there for a short time eh as far as I’mconcerned it was left open ye and I certainly never saw it getting closed.’

‘I witnessed Crew Manager from McDonald Road, he was then starting to break windowsat the front of the pub.’

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‘So if you’re standing looking at the main entrance to the pub, you know the entry… He wassmashing the windows to the right hand side of that.’

E5.7 FF Interview;‘so we’ve gone over to the cellar delivery hatch, which had been opened. There was thick smokepouring out of that’

‘I then witnessed eh from Mac Road being ordered to smash windowswith a hooligan tool.’

‘So he’s smashed the windows on either side of the entrance.’

E5.8 FF Interview;‘ and They were ready to be re-committed, came back to the board and tookthem round to Downfield Place before they went into air.’

‘He took them round to the corner… To check if it was feasible to make an entry into the basementthrough the cellar hatch at the pavement… Because that had been opened’

‘So eh the windows got put in… And that was purely to aide venting.’

E5.9 LBFRS Framework Operational Procedure 3.1, Fighting Fires in Buildings, Section 2 –Significant hazards and Risks, Ventilation of the fire [extract from pages 4 & 5] (Appendix 13)Ventilation of a fire in a building occurs in one of three ways:-• Fire will vent itself by burning through the structure that may or may not be designed for the

purpose• A consequence of other firefighting actions• Deliberate ventilation

In the case of deliberate ventilation, this is carried out either to aid casualty survival and facilitateLBFRS operations or as an integral aggressive part of firefighting.

E5.10 Dynamic Management of Risk at Operational Incidents, A Fire Service Guide [extract frompages 10 & 11]10

Dynamic management of risk is the continuous assessment and control of risk in the rapidlychanging circumstances of an operational incident.

Initial Stages of Incident

Upon the arrival of the initial attendance the first task of the Incident Commander must be to gatherinformation, evaluate the situation and then apply professional judgement to decide the mostappropriate course of action. Hazards must be identified and the risks to firefighters, the public andthe environment considered. The benefits of proceeding with a task must be weighed carefullyagainst the risks.

Comment: The action of venting the basement, and then the bar were not fully understood by theIC or the crews committed to the bar. The reasons for venting of the bar were not communicatedeffectively by the IC/SC to the crews. This resulted in the fire being vented without a completeunderstanding of the risk, without having located the fire and without all the crews committed intothe bar having sufficient protection.

There was insufficient consideration given to the length of time the fire had developed uncontrolled.

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E5.11 Fire Service Manual, Volume 2, Fire Service Operations, Compartment Fires and TacticalVentilation, Part 2, Tactical Ventilation [extract from page 23 & 24]11

7 Operational Command

Ventilation can only be one element of the overall firefighting strategy. It must be coordinated withother activities to ensure that differing requirements do not come into conflict. The decision to useforced ventilation will have further implications both for safety and for resources.

Sound tactical decisions, taken by officers responsible for the management of an incident, andeffective fire ground communications, are essential for the safe use of ventilation.

Any firefighters inside the building need to be able to inform the Officer-in-Charge of the conditionswithin the building, and are likely to be in the best position to advise on whether tactical ventilation islikely to be effective. In particular, they may be best placed to assess whether there arecompartments where there is a risk of a backdraught.

If the Officer-in-Charge decides that ventilation will be initiated, the firefighters inside must first beinformed. The Officer-in-Charge may decide to evacuate the building whilst ventilation takes placeand until conditions have stabilised. Particular care should be taken of the safety of firefighters onstoreys above the fire when ventilation is initiated.

If it is decided that the firefighters shall remain within the building, they will need to be able to informthe Officer-in-Charge when they are ready for ventilation to commence, and to report on theprogress of the ventilation. These firefighters need a hoseline to protect themselves.

Firefighters outside the building also need to have their activities coordinated. The firefighters makingthe outlet vent are likely to be out of sight of the inlet vent, but it is important that ventilation activitiesoccur in the correct sequence.

Whilst the fire is being fought, vents should only be opened as part of the ventilation plan, Careshould also be taken to ensure that key doors are not accidentally opened or closed duringfirefighting operations. Once the fire has been extinguished, ventilation can be increased.

E5.12 Summary and analysis of evidence indicating insufficient understanding of the effects ofventing the fire:• Early in the incident the beer hatch on Downfield Place was identified as a means of

access into the basement;• When the beer hatch was opened, no effective communication was made to all the

BA Teams within the building about this action;• There was no covering jet in place before the beer hatch was opened;• The beer hatch was left open;• The bar windows were smashed to try to relieve conditions inside without a full

understanding of the effect that would have on the fire;• The BA Teams inside the bar had not located the fire;• Communication with the BA Teams inside the bar was ineffective.

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E6 Ineffective briefing and debriefing of BA Teams to pass information about theaccess to the basement, conditions within the bar and the floor collapse, whichled to an insufficient assessment of the risk.There are several sources of evidence relating to debriefing BA Teams, including interviewtranscripts from WM (IC/SC), FF (BA Team 1), FF (BA Team 2), FF (BATeam 2), FF (BA Team 4), FF (BA Team 4), FF (BA Emergency Team 1),FF (BA Emergency Team 1)

E6.1 WM Interview;‘I gathered the two BA crews around, I said right well tell them what you’re telling me, as slow andconcise as you can, and he gave a pretty definite, simple and easy to follow kind of route. He hadalready pointed to the building to indicate where the office would be located, he had pointed to theright hand side of the building, down in the basement, but he said the access was down behind thebar, there was two or three steps to the bar, you then follow the bar round, round to the right, stickwith the bar and… not in so many words, but effectively take a left hand route, if you like, on the bar,you come to the top like, and you’re at the top of the stairs.’

‘Made sure the crews had understood the route, they were all quite happy with it, they knew wherethey were going and so we got to work.’

Question asked by Interviewer: ‘So what was, what was the brief for and

‘They were to get to the branch and assist the firefighting, again they were in, they had hose,remember telling me that there was, they had hose to get… they were now down the

bottom of the stairs and they were going down to assist and then kind of feed hose into thebasement.’

Question asked by Interviewer: ‘So Ewan and were down there to relieve the MacdonaldRoad crew?’

‘MacDonald Road crew, aye, I don’t recall them coming out, I don’t remember when they cameout.’

Question asked by Interviewer: ‘Right so they didn’t report to you when they came out?’

‘Not to me no.’

E6.2 FF Interview;‘Went back to entry control. Received our tallies’

Question asked by interviewer: ‘And did you give them a brief of what you’d encountered in thebuilding?’

‘Eh, basical…, yeah, well, said we’d got to the basement, left the branch, the line of hose was fed, itwas fed down into the basement, the branch was in the basement. Em, hadn’t located a fire.’

Question asked by interviewer: ‘And did you give the brief to or or someoneelse?’

‘I think, eh,

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E6.3 FF Interview;Comment: This extract relates to FF debrief after his first BA entry.

Question by Interviewer: ‘you’ve come out, em to at the entry control board?’

‘ was there as well. They, I think Ewan and more or less says what they had done. Iremember them saying they’d left the branch in the basement, em for whatever reason. I think theywere sure that other teams would be going in.’

‘Em, it was confirmed that the fire wasn’t out or we were pretty sure we hadn’t put the fire out.I remember standing on the pavement looking back into the building and the smoke I would saywas, if anything, was maybe slightly worse than it was when we approached’

I never passed on a lot of information because Ewan Williamson and they were the firefightingteam, eh, we were just assisting them and they were sort of saying that, I mean the 4 of us werethere but I was listening to what they were saying, the information they were giving was, wascorrect as in that they’d, a line of hose was in the basement, em that’s as far as they‘d got, they’dleft it there, em they didn’t think the fire was extinguished.’

Comment: This extract relates to FF brief and debrief for his second BA entry.

‘we were then briefed to go and assist Firefighter’s Williamson and with a hose reel’

‘So we exited and we came outside, the three of us came outside, collected our tallies, unmaskedand went to service our sets. Now I can’t remember seeing anybody at this point to pass anyinformation on to. I think there was a lot of activity outside by now eh. There was a lot of peoplegetting donned at the entry control point there was… it just seemed to be quite a clustered areawhen I came out, I remember it being quite a clustered area and that myself and and were basically just ripping our BA sets off trying to get cooled down at this point.’

Comment: This extract relates to FF brief for his third BA entry.

‘So we got our sets back, went to the entry control point and I think it sort of flowed as we says to“we know where he is, we’re going to get him” and was on the go and he says

you’re no going anywhere without your brief and says no you’re no in, this doesnae happensort of thing and we were sort of “but we know where he is we know exactly where he is just sort oflet us go and get him” eh and we explained where we were wanting to go to.’

‘so as I says we went back to entry control point, explained this information and then it then gotinterpreted into a brief… from We told him we knew where to go and he sort of… it wasalmost like a brief in reverse but knew exactly where we were going because we gave him thisinformation that had got and we gave that information to the entry control officer.’

E6.4 FF Interview;Comment: This extract relates to FF debrief after his first BA entry.

Question by Interviewer: ‘Did, did anybody debrief you when you got out?’

‘I don’t recall, I think we must’ve told, I think we told because I’m sure they were committingand from Mac Road.’

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Comment: This extract relates to FF debrief after his second BA entry.

‘…we’ve come out and basically gone along to the side d’you know what I mean we’re, we’vetaken a bit of heat now eh, obviously cattled. I got water, I think I asked for water, I got water.I realise that we’ve no’ collected our tallies I think I turned round to and says ken I’ll get thetallies so I’ve gone over to the entry control point, bit of chaos around there at this point d’you whatI mean there’s, we were shouting for emergency crews, guys are trying to get briefed ken what Imean there’s a general sorta everyone’s up y’know what I mean?’

‘So I’ve gone over and there’s chaos round the board em basically fuck off, fuck,y’know what I mean he was…’

‘…he was taking command o’ his area which is what he needed to do really… I walked away andhe went fuck off so I just stood there, waited. There was like a pause, a brief moment em and I thinkI said eh and so he’s given me and tallies eh, and I says is he out eh,and he never said anything he just looked at me and I, and I was like that, right, I walked over to

eh, gave him his tally and I says Hen’s still in there, I says we’re gonna have to go back in forhim eh, and like right so we’ve just, we’re taking water in, servicing our sets eh, y’know whatI mean we’ve just done, done a rapid service, gubbing water.’

Comment: This extract relates to FF debrief after his third BA entry.

‘…so we’ve made our way and eh, we’ve come out. We’ve come out and I was like that, I thinkwas it that told us, I think or I think try to tell you cannot send men to thatarea of the bar because the floor’s away, the floor’s going. You cannot send guys over there it’s,y’know what I mean…’

‘So, we’ve come out… eh, we went to the entry control. We informed him that you can’t send guysin to the right hand side of the bar. I said ‘the floor’s away, the floor’s away, you cannot send men tothe right hand side of the bar’.

‘I’d said to I says ‘I thought we were going to die’. He says ‘I thought we were going to die’.I says ‘I’m no’ going back in there’.

E6.5 FF Interview;‘I came out here and went to BA entry control.’

‘ was there…’

‘I told what we had done and that we had gas cooled and that we handed the branch over toEwan and

‘I told him that we had made our way to the basement and that the fire seemed to be directly aheadand behind a wall or something.’

E6.6 FF Interview;

‘Then we’d been told to mask up because… By because he wanted us to…’

‘Aye, he’s wanted us to go into the…’

‘Briefed us as we were masking up.’

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‘I couldn’t remember it word for word but we were going in and we were to make our way to thebasement we’d take a hose reel in with us, locate the fire and extinguish the fire.

‘…we got told that to go, to get to the basement as soon as you hit the bar you were going left andyou’d locate the stairs to get to the basement.’

‘Then I think as I say it was to turn left and you’d get to the stairs, descend the stairs into thebasement, locate and fight the fire.’

Question asked by Interviewer: ‘So have you been debriefed by someone when you’ve cameout?’

‘I think it was that was there that we’ve told what we’ve actually done.

E6.7 FF Interview;‘somebody’s no come oot the pub or a team’s been split…’

‘So then we were then getting asked… what I’ve took oot this brief period of time was, there’s naenames mentioned, it was just a firefighter had become split and it was… even then it was still quiterelaxed it was like ah he’s in the rear of the pub but then… I was a bit confused because I heardsomebody saying he was trapped or he had fell or something.’

‘… you know there was definitely… he was in a position but he couldnae get oot… At that precisetime I cannae remember the toilets being mentioned, I’m sure that was mentioned as we had gonetowards going into the pub but it was basically… the brief was basically that we had to go in andget the firefighter and help him oot…’

‘…somebody then said you’ll hear his DSU going off and I cannae remember if had come overat that time but there was, as I say, there was a lot of people chatting, shouting. DSU was definitelymentioned, you’ll hear the DSU and I was like oh that’s fair enough like ken, I’ve nae idea, I’ve neverbeen in the pub before, I didnae ken the depth of it or what the breadth was or whatever. We weretold the DSU, we’d hear the, the DSU to go in through the front and follow the hose and off the righthand side of the hose, to follow that and it wasnae really and you’ll locate the toilet, and I’m hearingthat as we’re going in and there was nane of this then you go to the BA entry controller and just saywhat your brief was cause your brief was sort of changing every 10 seconds you know what Imean.’

‘there was a line of 45 I think and 2 hose reels.’

‘So I went in, it turned out it was a big bight but then appeared to be a hatch so then I’m gettingconfused, I’m thinking why is this going behind the bar… then I’m thinking when did they actuallymean come off the hose if you know what I mean to take… it wasnae like take a right hand search,a left hand search… nothing like that. It was follow the hose and off the right… the hose you’ll thenreach the toilets, that’s how I remember it.’

‘So I’ve then got.’

‘… to tell this and where has he gone.’

‘I touched him and he’s shouting at me here I’ve got further information. They had told himsomething different…’

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‘So then he’s started to tell me that he says no, he had spoke to or somebody outside,they had got information from the manager or something that the toilets were to the right of the bar,right along the right hand wall to the rear of the pub and that’s where we had to go.’

E6.8 FF Interview;‘…it was that gave us our brief…’

‘And things become… obviously there’s a guy in there so there’s things that are getting passedback and forward about him trying… about where he is and things like that. We were briefed byWatch Manager to follow the hose into the building until it turned left behind the bar andwhen it turned left behind the bar we were to proceed straight ahead to double doors, passedthrough the double doors to the toilets which were located on the right hand side, so that was thebrief we got from Watch Manager

‘Well, just before… as I was about to enter the building, Watch Manager come up to me…was already in… going in the front door.’

‘Watch Manager come up to me and grabbed me so I stopped from going in, wasstanding there and Watch Manager confirmed to me the FF Williamson was at the back of theground floor in the Male toilets on the right hand side.’

‘So he confirmed that with me before… after he gave me the initial brief, he come back to me andas we were going in, he stopped me from going and I stopped and he told me he wasdefinitely in the toilets.’

E6.9 Summary and analysis of evidence indicating ineffective briefing and debriefing of BATeams to pass information about the access to the basement, conditions within the barand the floor collapse, which led to an insufficient assessment of the risk:• Initial BA Teams (BA Team 1 & 2) were not asked, and did not provide effective

information about the conditions inside the bar and basement;• Information was not effectively gathered or communicated between subsequent BA

Teams and IC/SC;• Information received from BA Teams was not effectively included in briefs for further

BA Teams;• BA Teams continued to be committed to the bar despite the floor collapse.

E7 The means of escape for successive basement firefighting crews and BAEmergency Teams was not effectively maintained.There are several sources of evidence relating to the means of escape not being effectivelymaintained including, WM (IC/SC), FF FF FF FF and FF

E7.1 WM Interview;Question asked by interviewer: ‘When you were discussing the hatch as an alternative means tothe basement, did the landlord at any time tell you about the emergency exit in, in the stair, thecommon stair?’

‘Didn’t know about that at all, I didn’t know about that door at all. He told us about the fire exit at theback which, erm, I knew… That’s what, I think was on the case of that anyway, erm, but no.’

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‘No I didn’t know about that at all… We didn’t know about it at all. Erm, and obviously seenphotographs since and seen where that door is and thinking things could have been different if youhad used it, but, you know, having said that could have comprised the stair even more, a lot ofactivity in the stair at that time still…’

E7.2 FF Interview;Question asked by interviewer: ‘When you got to this part here, do you remember this doorleading into that stair?’

‘A door leading into it… No.’

E7.3 FF Interview;Question asked by interviewer: ‘Do you recall that emergency exit door there?’

‘No, nut. I don’t.’

The following extract describes when FF was committed as a BA Emergency team.

Question asked by interviewer: ‘Right, so you’ve come back, you’ve got the brief or exchangedthe brief with and

‘ handed our tallies over em entered the building.’

Question asked by interviewer: ‘Did you have anything with you at this point?’

‘No… as in extinguishing…’

Question asked by interviewer: ‘Either extinguishing or EASE equipment?’

‘No it was just ourselves… was just ourselves.’

E7.4 FF Interview;Question asked by interviewer: ‘So you masked up, have you been …have you taken the hosereel?’

‘No, I never took anything whatsoever in with us.’

E7.5 FF Interview;‘…we’ve masked up and myself and were going into the pub.’

Question asked by interviewer: ‘So yous headed to go in the pub, handed your tallies to the BAentry controller?’

‘Ye, ye.’

Question asked by interviewer: ‘Hose reel?’

‘Na, nothing.’

Question asked by interviewer: ‘No equipment at all?’

‘Nothing.’

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E7.6 Summary and analysis of evidence indicating that the means of escape for successivebasement firefighting crews and BA Emergency Teams was not effectively maintained:• The IC was not informed about the existence of the emergency exit leading from the

bar into the common stair at 1 Downfield Place;• Initial teams did not locate the emergency exit inside the bar;• BA Teams were deployed into the risk area without firefighting medium.

E8 Ineffective cordons and control of the incident ground outside the bar.There are two sources of evidence for the ineffective cordons. These are CCTV footage and aninterview transcript from WM

E8.1 CCTV Footage timed at 01:09.09This CCTV footage shows a Firefighter deploying hazard warning tape between the bus stopoutside 172 Dalry Road, appliance 512 and over to the petrol station.

E8.2 CCTV Footage timed at 01:33.48Smoke issuing from the bar increases significantly. Main area of operations in Sector 1 continueswithin the smoke.

E8.3 CCTV Footage timed at 01:34.31BAECB is relocated approximately 3 metres from where it was initially sited.

E8.4 CCTV Footage timed at 01:39.00Smoke issuing from the bar increases significantly. Several Firefighters outside in Sector 1 retreat toescape the smoke. Operations within Sector 1 continue from the same location.

E8.5 CCTV Footage timed at 01:45.31Smoke issuing from the bar increases significantly. Operations within Sector 1 continue from thesame location.

E8.6 CCTV Footage timed at 01:55Smoke issuing from the bar increases significantly and covers the entire roadway. Operations inSector 1 continue from the same location.

E8.7 CCTV Footage timed at 02:20Smoke issuing from the bar increases significantly. Operations within Sector 1 continue from thesame location.

E8.8 CCTV Footage timed at 02:27.33Smoke issuing from bar increases for a sustained period. Operations within Sector 1 continue fromthe same location.

E8.9 WM Interview;‘I still had no idea at that point eh what had happened. Em so, then I was just kinda standing thereon my own waiting on coming back. Eh, he came back and told me that he definitely wantedme to set up main control.’

‘And he said just to go and find a suitable place to set it up and let him know when I’d done so. So Iheaded back up to sort of eh along Dalry Road eh I sort of had it mind you know that I’d seen the busshelter because the… em weather was, I think it was raining at that point… So I thought well you know, itwould be, maybe okay but then when I got there I thought well no, the garage forecourts gonna be better.’

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‘I, I think it was about back o 2 and I think it was about ten past 2 I set up main control… Probablytook, you know sort of eh once we started setting up you know it maybe took about 10, 15 minutesto, you know…’

E8.10 Summary and analysis of evidence indicating that there were ineffective cordons andcontrol of the incident ground outside the bar:• Several instances throughout the CCTV footage show the location for firefighting

operations to be within the risk area;• BA Teams congregating within the smoke plume despite BA Main Control being in

operation.

F. Why did it happen – Organisational underlying causes

F1 IntroductionThe following subsections set out evidence and views as to whether and/or how they contributedas organisational underlying causes. These factors are:• Resources (F2);• Procedures (F3);• Training (F4).

F2 Evidence relating to resources

F2.1 Resources have been separated into:• Appliances and Officers;• Equipment;• Personnel.

F2.2 Appliances and Officers

AppliancesThe investigation has established that there were two types of emergency at this incident:• A fire in a basement;• Multiple rescues from houses with multiple occupation of persons suffering smoke inhalation.

Generic risk assessments by type of emergency were established for the fire service in 1998.The two types of emergency established by the investigation are covered by:• GRA 2.7 rescues from height, and;• GRA 3.1 fighting fires in buildings.

GRA 3.1 identifies that fires below ground present a number of unique problems. Adequatearrangements are required to identify premises that offer a significant risk and pre-plan operationaltactics that are supported by appropriate training.

The Regional Control Centre project in England established 87 different types of emergency that itwas reasonably foreseeable that Fire and Rescue Services would likely attend. The types ofemergency present at the this incident would be consistent with:• Incident No. 36 – Fire;• Incident No. 67 – Rescues from height.

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These emergency types should have been further defined by the outcomes expected by LBFRS intheir IRMP.

There is no evidence that the Board and LBFRS had adequate arrangements required to identifypremises that offer a significant risk or that they had pre-planned operational tactics that weresupported by appropriate training for all operational staff.

This lack of planning meant the Command and Control Systems used at this incident were set to fail.

The first call to LBFRS was received at 00:38 and the correct PDA (three pumping appliances andone height appliance) was mobilised. The first four appliances were alerted to the fire at 00:39, withthe first appliances (301 and 302) arriving at 00:42. The entire initial PDA was in attendance by00:45.

Control Staff received information from Police Control which identified cylinders may be present inthe premises. This was not communicated to the incident ground.

The resources mobilised were insufficient due to the scale of the incident and there were notenough appliances or personnel mobilised during the early stages of the incident in order that thecrews could effectively and safely deal with the situation they were confronted with.

During the incident, the IC requested additional resources which culminated in 12 pumpingappliances, one TTL, one CSU, one BA Support vehicle, one MIU, one FIU and eight CommandOfficers being in attendance during the investigation period up until 03:21.

The sequence that appliances were requested was as follows;

Confirmed fire 1 (00:47)FDS Officer (call sign 30) and FIU (564)

Make Pumps 4 (00:50)One pump (512), one MIU (364), CSU (325) and one FDS Officer (12)

Make Pumps 5 (00:55)One pump (502), BA Support Vehicle (86) ISU (524) and three FDS Officers (06, 20 and 50)

Make Pumps 7 (01:29)Two pumps (331 and 511) and two FDS Officers (11 and 75)

BA Emergency (01:34)One pump (501)

Make Pumps 9 (01:54)Two pumps (312 and 392) and FDS Officer (02). Chief Officer informed

Make Pumps 11 (02:12)Two pumps (381 and 541)

All pumping appliances mobilised from their home station, attended the incident within 10 minutesof being informed. During the escalation of the incident LBFRS Control Operators moved unusedappliances to strategic station locations throughout LBFRS area to provide fire cover. Oncerequested, all appliances attended the incident in good time.

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For an incident of this size, on attendance the IC should have immediately requested additionalresources to deal with the multiple rescues that were required from the tenement stair. It took until01:36 before a ‘fully capable team’12 was in attendance at the incident (the arrival of sixth PumpingAppliance, 331).

When the incident was declared as Stage 2 Entry Control Procedures (ECP) in operation at 00:48, adiscussion took place within the Control Room as to whether Stage 2 ECP required a make up.Almost immediately, the Control Operator responded on radio;

‘301 can you confirm this is stage 2 and confirm if this is a make pumps 4, ZF over.’

The ‘make pumps 4’ was confirmed by 301 at 00:50.

At 01:24, Control Operators received a message from the incident ground asking to confirm whatthe fifth pump to arrive at the incident was. Control Operators confirmed the fifth pump was 502.This appliance arrived at the incident at 01:03.

After the BA Emergency was declared at 01:34 a further make up was requested at 01:54, thismessage requested ‘make pumps 9’. At the time when this ‘make up’ message was received therewere already nine pumps allocated to the incident. This included the BA Emergency pump.

Control Operators were unclear if they needed to mobilise a further pump and telephoned CSU toconfirm the exact number of pumps required. This was confirmed and a tenth pump was mobilisedat 01:57.

OfficersWhen the incident became a confirmed fire (00:47), the Incident Command and Control System(ICCS) dictates that the incident is categorised as a ‘Level 2 incident’. Control Operators mobilisedFDS Officer (call sign 30). The first FDS Officer (30) was mobilised in accordance with the publishedofficer’s duty roster. FDS Officer 30 was mobilised by 00:53 but did not arrive at the incident until01:22 and was the third FDS Officer to attend. This was solely due to the geographical location thatFDS Officer was mobilised from.

PersonnelThe appliances in the initial attendance (301, 302, 311 & 303) were crewed with two WatchManagers (WM) two Crew Managers (CM) and 12 Firefighters. All appliances in the first attendancewere crewed at the minimum level.

At the initial attendance, two Firefighters were in the development phase of their training. During theincident, until 03:21, there were a total of 11 firefighters in attendance who were within thedevelopment phase of their training.

The Officers in charge of the pumping appliances of initial attendance were all carrying out theirsubstantive roles. The OIC of the TTL was a temporary Crew Manager.

During the incident, there was one further Officer on the incident ground that was carrying out atemporary role; FDS Officer 11 was temporary promoted from Group Manager (B) to Area Manager.

During the incident there were several firefighters in attendance that were still within thedevelopment phase of there training. On at least one occasion, two Firefighters in developmentwere committed in BA into the incident.

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F2.3 Summary and analysis of evidence relating to Resources as potential organisationalunderlying causes:• Insufficient resources were mobilised to deal with two types of emergency at this

incident;• Control Operators did not pass information received about cylinders to the incident

ground;• Control Operators identified that Stage 2 ECP required the mobilisation of a further

pumping appliance;• There was confusion on the incident ground about the attendance of the fifth

pumping appliance (502);• No consideration given to the number of personnel in attendance on the incidence

ground;• There was confusion around the number of pumps required after the BA Emergency

was declared;• The mobilisation of FDS Officers to incidents takes no account of their geographical

location;• On the incident ground there was no identification of Firefighters in development

phase of their training.

F3 Evidence relating to Procedures

F3.1 IntroductionProcedures have been separated into:• Lothian and Borders Fire Board Integrated Risk Management Plan (IRMP);• Operational Risk Assessment Model (ORAM);• Current LBFRS Operational Procedures;• Current LBFRS Operational Procedures on Incident Command;• Current National guidance on Operational Procedures.

F3.2 Lothian and Borders Fire Board Integrated Risk Management Plan (IRMP)The Board do not produce a suitable and sufficient IRMP. The investigation team found evidence ofthe following:• LBFRS Service Improvement Plan 2005/10 (Appendix 25);• LBFRS Performance Plans 2007 & 2008 (Appendix 26 & 27);• LBFRS Service plans 2002, 2003, 2004, 2005 & 2006 (Appendix 28 to 32).

The investigation team could not find evidence that the IRMP adequately met the statutoryrequirements of fire and rescue legislation or health and safety legislation.

F3.3 Operational Risk Assessment Model (ORAM)LBFRS operates a Health and Safety System titled Operational Risk Assessment Model (ORAM).This system was introduced into the Service in 1999 and is based around the Health and SafetyExecutive guidance HSG65. The FRS describes the ORAM as a simple and easily understooddisplay of the steps taken in the process of Operational Risk Assessment.

The model is broken down into six parts:1. Information sources;2. Generic Hazard Analysis (GOHA);3. Site Specific Assessment;4. Generic Incident Types;

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5. Dynamic Risk Assessment;6. Audit and Debrief.

For the ORAM to function correctly, it requires the FRS to continually update all aspects of the FRSprocedures and practices using the information generated from ORAM relating to the six parts listedabove.

F3.4 Current LBFRS Operational Procedures

Framework Operational Procedures (FOP)LBFRS use FOP’s to detail the hazards, risks and control measures applicable to various incidents.The FOP’s are used as a framework to form an integral part of the risk assessment made by the ICwhen dealing with an incident.

FOP 3.1 deals with Fighting Fire in Buildings. This FOP is included in Appendix 13.

All FOP’s are available in electronic format from LBFRS Intranet system. They are not held in paperformat in fire stations, and therefore are not readily accessible to all.

FOP 3.1 concentrates on large or unusual buildings such as ‘Buildings of complex design orconstruction, large insulated sandwich panels, large uncompartmented buildings, buildings underconstruction/demolition and Dangerous buildings.’

There is no FOP for compartment fires in general or fires in basements.

There is also no written procedure or FOP for tactical ventilation.

F3.5 Current LBFRS Operational Procedures on Incident Command (Appendix 14)LBFRS has introduced an Incident Command and Control document which details the level ofincident and the appropriate command structure that will be mobilised.

This guidance is based on the framework contained within the Fire Service Manual, Volume 2, FireService Operations – Incident Command 2002.

The ICCS document is available on LBFRS Intranet system but paper copies are not readilyaccessible to all.

F3.6 Current National Guidance on Operational ProceduresCurrent national guidance for operational procedures falls into the following categories:1. Incident Command;2. Operational Risk Assessment;3. BA Command and Control Procedures.

Incident CommandThe Department for Communities and Local Government (CLG) issued Fire and Rescue Manual,Volume 2, Fire Service Operations, Incident Command, 3rd Edition in 2008 and is the currentnational guidance for UK FRS.

Operational Risk AssessmentHMFSI has produced guidance titled A Guide to Operational Risk Assessment, Health & Safety, FireService Guide, Volume 3, updated 2004. This document contains 36 Generic Model RiskAssessments and provides practical guidance on how the assessments may be used by brigades.

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This document was recently superseded in August 2009 by Fire and Rescue Service OperationalGuidance, Generic Risk Assessments introductions, Guidance for Fire Services.

BA Command and Control ProceduresBA Command and Control Procedures are detailed within Technical Bulletin – 1/1997, BreathingApparatus, Command and Control Procedures.

Fire Research Technical Report 2/200513 was available to LBFRS which should have resulted in areview of BA control procedures.

F3.7 Human Failure and AccidentsIn 1989 the Health and Safety Executive published Reducing error and influencing behaviour(HSG48), the latest edition was published in 2009. This document states;

Accidents can occur through people’s involvement with their work. As technical systems havebecome more reliable, the focus has turned to human causes of accidents. It is estimated thatup to 80% of accidents may be attributed, at least in part, to the actions or omissions of people.This is not surprising since people are involved throughout the life cycle of an organisation, fromdesign through to operation, maintenance, management and demolition. Many accidents areblamed on the actions or omissions of an individual who was directly involved in operational ormaintenance work. This typical but short-sighted response ignores the fundamental failureswhich led to the accident. These are usually rooted deeper in the organisation’s design,management and decision-making functions.

Over the last 20 years we have learnt much more about the origins of human failure. We cannow challenge the commonly held belief that incidents and accidents are the result of a ‘humanerror’ by a worker in the ‘front line’. Attributing incidents to ‘human error’ has often been seenas a sufficient explanation in itself and something which is beyond the control of managers. Thisview is no longer acceptable to society as a whole. Organisations must recognise that theyneed to consider human factors as a distinct element which must be recognised, assessed andmanaged effectively in order to control risks.

The HSE call this ‘Human Factors’ and The HSE definition is;

‘Human factors refer to environmental, organisational and job factors, and human andindividual characteristics which influence behaviour at work in a way which can affect healthand safety’.

Human factors fall into three aspects: the job, the individual and the organisation. Each factor hasan impact on people’s health and safety-related behaviour.

People can cause or contribute to accidents (or mitigate the consequences) in a number of ways:

The Human Contribution to AccidentsPeople can cause or contribute to accidents (or mitigate the consequences) in a number of ways:

Through a failure, a person can directly cause an accident. However, people tend not to makeerrors deliberately. We are often ‘set up to fail’ by the way our brain processes information, by ourtraining, through the design of equipment and procedures and even through the culture of theorganisation we work for.

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People can make disastrous decisions even when they are aware of the risks. We can alsomisinterpret a situation and act inappropriately as a result. Both of these can lead to the escalationof an incident.

The consequences of human failures can be immediate or delayed.

Active failures have an immediate consequence and are usually made by front line people such asappliance drivers, control room staff, Incident commanders and firefighters. In a situation wherethere is no room for error these active failures have an immediate impact on health and safety.

An example of active failures

The operational imperativeOn the arrival of crews, there will be an expectation of action. Operational crews face pressureto act, particularly when large crowds are at the scene of a serious incident. Evidence fromaccident investigations has shown that firefighters will attempt tasks regardless of the resourcesavailable to them risking death or serious injury.

Evidence from accident investigations has shown that some incident commanders will attempttasks regardless of the resources available to them risking death or serious injury.

Latent failures are made by people whose tasks are remote from operational activities, eg planners,decision makers and managers. Latent failures are typically failures in health and safetymanagement systems (design, implementation or monitoring). Examples of latent failures are:• Poor integrated risk management planning;• Poor monitoring and review of performance;• Ineffective training;• Inadequate supervision;• Ineffective communications;• Uncertainties in roles and responsibilities.

Latent failures are usually hidden within an organisation until they are triggered by an event likely tohave serious consequences.

An example of latent failures

Inappropriate and/or insufficient resources to provide safe systems of work for the FRS taskThere is a societal expectation that a firefighting team will arrive and achieve something.Evidence from accident investigations has shown that firefighters will attempt tasks regardlessof the resources available to them risking death or serious injury.

Currently LBFRS rely on Dynamic Risk Assessment (DRA) as the process for dealing with operationalincidents. “Dynamic Management of Risk at Operational Incidents”14 as a basis for their policies,procedures and training. The purpose of the DRA process was for crews working autonomously but itis applied in LBFRS as a risk assessment in an unrecorded dynamic format, based on whatoperational staff see and what the employer perceives as the employees underpinning knowledge. Asuitable and sufficient risk assessment is the employer’s responsibility under the Management ofHealth and Safety at Work regulations 1999(MHSWR 1999) Regulation 3 which requires all employersto assess the risks to all employees and any others that may be affected by their undertakings.

The Fire and Rescue Framework for Scotland 2005 makes clear the statutory and non-statutoryoutcomes the Scottish Government requires of Lothian and Borders Fire Board.

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To carry out these functions the Board must secure the provision of the personnel, services andequipment necessary efficiently to meet all normal requirements; secure the provision of training forpersonnel; make arrangements for dealing with calls for help and for summoning personnel; makearrangements for obtaining information needed for the purpose of delivering these functions andmake arrangements for ensuring that reasonable steps are taken to prevent or limit damage toproperty resulting from action taken for the purposes listed above.

They also have a duty to comply with other legislation to provide a work place that is safe, fair andfree from discrimination. Lothian and Borders Fire Board must have regard to the Approved Codesof Practice and guidance that assist compliance with the law.

The Board must identify the types of emergency they respond to and the outcomes they expect toachieve by this response.

LBFRS must assess the risks to firefighters from each type emergency. This is impossible to do ifthe outcomes for each type of emergency are not made clear within the IRMP.

F3.8 Summary and analysis of evidence relating to procedures:• Despite the national guidance being revised and reissued in 2008, LBFRS have not

updated their Incident Command and Control procedures since 2006;• There are no individual FOP for compartment fires, basement fires or for tactical

ventilation;• There is only electronic access to FOP’s and other LBFRS procedures. There is no

paper based system on fire stations to allow all firefighters unrestricted access toLBFRS documents;

• There is limited access to national guidance contained within Fire Service Manuals,Guide to Operational Risk Assessment Volume 3 and Technical Bulletin TB1/97;

• Human factors had a significant impact at this incident. Crews and IncidentCommanders acted without having the appropriate resources available on theincident ground;

• Organisational failures had a significant impact on this incident. Poor IRMP, undefinedexpected outcomes, inadequate training, ineffective supervision and ineffectivecommunications all had a significant influence on the incident;

• Inadequate assessments of risk, which has contributed to poor management of riskat this incident.

F4 Evidence relating to Training

F4.1 IntroductionWhen considering the potential for training issues to be considered as significant in the context ofthis investigation, the following have been selected as relevant:• LBFRS Brigade Training Policy Statement;• Continuation training, development and assessment;• Real/Hot fire training;• Incident command training and assessment;• Recording and monitoring training and outcomes.

F4.2 LBFRS Brigade Training Policy StatementLBFRS Brigade Training Policy Statement is detailed in Brigade Order (BO) F1 (Appendix 15)

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The Training Policy statement was introduced by LBFRS in July 1999.

The policy sets out LBFRS responsibilities for training as well as staff roles and function, strategicplanning, training delivery, and review. The following documentation supports the overarchingpolicy;

Appendix 1Training and Development Plan – Operational Roles (Appendix 16)

Appendix 2Training and Development Plan – Technical and Administrative Roles (Appendix 17)

Appendix 11Training Practice Statement – The Operation of Training for Competence (Appendix 18)

Appendix 12Training Practice Statement – Assessment: General Principles and Arrangements (Appendix 19)

Appendix 13Training Practice Statement – Dynamic Management of Risk (Appendix 20)

Appendix 14Training Practice Statement – Training Safely & Realistic Training (Appendix 21)

F4.3 Continuation training, development and assessmentIt is not clearly defined within the Training Policy documents how continuation training should beorganised, who should provide it, what should be provided or what resources are available. Thedocument ‘Training and Development Plan – Operational Roles’ (Brigade Order F1 Annex 1)identifies seven ways in which training and development needs can be highlighted but it is not clearwhere continuation training fits within those identified areas.

Brigade Order F1 Annex 1 states;

6.2 Standards and AssessmentOperational Training is based on the need for individuals and groups to meet the standardsdocumented in the JTC report “Fire Service Standards”. Interpretation of the standards, and crossmapping to specific training objectives and outcomes, is carried out by the Divisional Officer,Individual Development.

Assessment to the standards is made in accordance with the JTC guidance “A Best Practice forAssessment” (Central Fire Brigades Advisory Council), which is interpreted in the Training PracticeStatement “Assessment: General Principles and Arrangements”

We have been unable to obtain the JTC Report and JTC Guidance.

The Training Practice Statement “Assessment: General Principles and Arrangements” states;

2 BackgroundFire Service training and work performance has always included an element of assessment. Eachtime a Watch Commander tackles an operational incident or attends an exercise, they areassessing the ability of their watch, and of the individuals in the watch, to deal with that incident. Ifshortcomings in skills are identified, then the Watch Commander will normally arrange refresher

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training on the subject or skill area. Training for Competence is, in a sense, a way of formalising thatprocess and ensuring that the necessary training is carried out to an appropriate level.

6 Assessing against risk assessments and training scenariosThe assessment of operational competence, and hence the operational training which isundertaken, is based on the need for a watch or retained station to deal effectively and safely with adefined set of hazards. Those hazards have been analysed and published as a set of riskassessments. The published risk assessments therefore form part of the documentation necessaryto ensure that watches and individuals have been trained appropriately.

The practice statement does not state where the ‘published risk assessments’ can be accessed.

It also implies that these general principles for assessment of operational competence only apply atfire station level. There is no reference to assessment of competence for Watch Commander.

Continuation training material is mainly based around computer training packages. These areprovided by the Scottish Fire Services College and cover a variety of subjects. In terms of BreathingApparatus and Firefighting these include:• Domestic Property;• Commercial/Office Properties;• BA Procedures & Firefighting – High Rise Incidents;• BA Operators Entry Control Officer;• Working and Moving in Smoke and Darkness;• BA Search Procedures.

There is limited opportunity for operational personnel to be involved in multi pump incident training.This includes large scale breathing apparatus exercises which include the use of BA Main Control.

F4.4 Real/Hot fire trainingBrigade Order F15 (Revised) details the Wholetime and Retained Breathing Apparatus Training forLBFRS (Appendix 22)

The Fire Service guidance for the provision of hot fire training is contained in Fire Service Circular17/1970. This circular was produced on 24th April 1970 and is titled ‘Breathing Apparatus: BasicTraining of Wholetime Men’

The circular states;

3 The Secretary of State recommends that all breathing apparatus wearers should attend a 2-3day refresher course at 2-yearly intervals, and that a fireman who has not worn breathingapparatus at a fire during any period of 12 months should have refresher training in heat andsmoke, wearing the type or types of breathing apparatus normally used in his brigade.

LBFRS employs a training regime where every operational firefighter (all roles) should attend theServices training facility, the Scottish International Fire Training Centre (SIFTC), for one day hot firetraining at least once per calendar year. The training provided at the SIFTC revolves around preplanned training scenarios using the hot fire units based at Fillyside or McDonald Road. The trainingscenarios change each year and have a common theme throughout each training year.

Delivery of the training is conducted by operational staff from the Training Function.

The training provided does include BA Command and Control Procedures.

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The Operational Refresher training course 2009/10 is included in Appendix 23 as an example ofwhat the SIFTC provides.

F4.5 Incident command training and assessmentIncident Command training material is provided for all operational roles to access within LBFRS. Thetraining provided for station personnel is as follows:• Firefighters are introduced to the principles of Operational Incident Command during their initial

training at Scottish Fire Training College (SFTC);• Firefighters receive computer based presentations on Incident Command and Control at station

level, delivered by Crew or Watch Managers; • This training includes BA Entry Control and communications;• Part of the promotion selection criteria is an operational competence assessment. This is

carried out using the Vector computer simulator;• Crew and Watch Managers do not receive specific ongoing training on ICCS other than that

delivered by them on station;• Crew and Watch Managers have the opportunity to practice ICCS during the annual BA

refresher training. This is organised centrally by LBFRS Training Function.

Incident Command training facilitated by Training Function is conducted using Vector computersimulator. External command training is provided by Strathclyde Fire and Rescue Service (SFRS)using Minerva incident simulator:• Vector is a computer based incident simulator and provides training and assessment of incident

command to operational firefighters from Crew Manager to Group Manger. The simulator allowsthe incident to evolve dependant on decisions taken by the individual who has taken the role ofIncident Commander;

• The Minerva training provided by SFRS allows assessment of incident commanders Bronze,Silver and Gold levels of command.

A structured programme for ICCS training was instigated by Operations Planning in 2009. This hassince been taken within the Training Function and delivers ICCS Level 3 training for GroupManagers.

F4.6 Recording and monitoring training and outcomesSince 2007 LBFRS uses the PDR Pro computer system for recording and monitoring training givento Operational Firefighters. The system is available on all LBFRS computers through the Intranetsystem. The system relies on the user inputting the development activity, the relevant module theactivity covers and each of the elements within the individuals role map that have been coveredduring the training. This computer system can be interrogated by the line manager to monitorindividuals training and highlight and address any training development needs highlighted.

F4.7 Summary of evidence relating to Training: • LBFRS Training Policy and associated Annexes do not clearly define the

responsibilities of each line manager in delivering training to operational personnel;• Documents referred to within the Training Policy are not readily available on

stations; • The objectives of continuation training are not clearly defined;• Continuation training for Watch Managers is not provided or delivered effectively;• Support for delivery of station based training is poor and provision of training facilities

and off site locations is not managed effectively;• Provision of hot fire training is not managed effectively to ensure that all operational

personnel attend on at least one occasion throughout the training year;• There is no regular structured training for fire behaviour;

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• There is no regular structured training for ventilation;• Continuation training for ICCS Level 2 training of Watch and Crew Managers is not

effectively managed;• Continuation training for ICCS Level 3 and above is not effectively managed;• Recording of training using PDR Pro computer system is generic;• Training for the use of PDR Pro is not effective.

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5 Conclusions

The tragic loss of Ewan’s life on the 12 July 2009 had a number of causes which we believe are attributed toa series of failures by the then Lothian and Borders Fire and Rescue Service.

Failures in planning, resourcing, training and the collection of risk information all attributed to the cause ofEwan’s death.

These causes have been outlined below in a number of sections:• Immediate causes;• Underlying causes identified from the incident;• Organisational underlying causes.

5.1 Immediate Causes5.1.1 FF Williamson and FF were recommitted, in BA, to the basement with minimal recovery

period between BA wears. Both FF exited the bar at approximately 01:07 and were recommittedinto the basement at 01:17. Based on evidence produced in this report, there was insufficient timebetween BA wears for FF Williamson and FF to recover. It is likely that both their core bodytemperatures did not have sufficient time to recover before the second BA wear. This is likely tohave caused heat stress.

It is custom and practice in LBFRS to redeploy BA teams at an incident without properconsideration of the effects of heat and humidity.

5.1.2 The basement and ground floor of the bar were vented before the fire was located. The basementfirefighting teams were not withdrawn prior to venting. There was ineffective communicationbetween the IC and the committed BA teams.

As the fire had not been located, no water was applied. This allowed the fire to develop aided by theuncontrolled and unplanned ventilation.

5.1.3 No water was applied to the fire.

5.1.4 Whilst exiting the building FF Williamson was separated from his BA partner and became trapped ina toilet. While making their way out of the bar the BA team lost physical and verbal contact. Theconsequence of this was FF Williamson did not exit the front door of the bar and became trappedto rear of the bar.

5.1.5 There was a significant collapse of the ground floor structure. The area of the collapse preventedany access to or egress from the toilets. There are various factors which could have contributed tothe collapse of the floor, these include:• A continuing developing fire;• The fire loading within the premises particularly the basement;• The construction of the building;• The state of repair of the floor;• Ventilation of the bar;• The main seat of fire not being located.

Despite repeated efforts, BA Teams were unable to access the toilets at the rear of the bar becauseof the extent of the floor collapse.

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5.1.6 The consequence of all of the immediate causes was FF Williamson was fatally exposed to fire andextreme heat.

5.2 Underlying Causes identified from the Incident

5.2.1 Insufficient understanding of the types of emergency and the expected outcomesControl room staff failed to pass on vital information and did not seek further information of the incidentfrom the callers. Resources mobilised were not suitable for the types of emergency at this incident.

Incident Commanders failed to understand that they were facing two types of emergency. thisfailure led to implementation of tactical plans that were not effective or safe. The types of emergencyat this incident were:• A fire in a basement, and;• Multiple rescues from a house of multiple occupation of persons suffering smoke inhalation.

Rendezvous point, marshalling area, safe and hazard zones needed for effective control ofresources and the public were not established

Incident Commanders were set to fail. They could not gain and maintain adequate control of theincident

The fire was fed by uncontrolled and unplanned ventilation of the basement and ground floor.

5.2.2 Insufficient understanding of the effects of recommitting BA Teams to the bar with minimalrest period between BA wears, which led to an insufficient assessment of the risk.On arrival at the incident there were 16 Firefighters in attendance, during the initial deployment of BATeams, six firefighters were utilised, four of whom were committed into the bar. The identified accessto the fire compartment required the BA Teams to pass over the top of the fire and down stairs,through a heat barrier, into the basement. From the attendance of the first appliance it was clearthat there was a developing fire within the bar. The initial reports were that the smoke was down tofloor level and BA Teams confirmed this when they exited the bar.

The two BA Teams who exited the bar were seen to be ‘steaming’ due to the heat within the bar.When outside the bar, all four firefighters immediately prepared themselves for re-entry. This iscustom and practice within LBFRS.

When recommitting BA wearers, the IC and firefighters did not take account of the hazards within thebar. There was no consideration of the recovery period for each of the BA wearers. The heat, locationof the fire and difficulty accessing the basement, along with the recovery period for the BA wearerswere not properly analysed which led to an insufficient understanding and assessment of the risk.

5.2.3 Insufficient understanding of the causes and effects of heat stressBA Teams were re-committed several times into the fire compartment. The effects on cognitivebehaviour from an increase in core body temperature are well known and documented.15

5.2.4 Insufficient understanding of effects of venting the fireEarly in the incident the beer delivery hatch was identified as a means of access into the basement.Once it was unlocked it was left open.

At 01:20 the windows begin to be opened up at the front of the bar. This was to improve conditionsinside the bar.

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Unplanned ventilation of the fire began when the beer delivery hatch was opened; furtheruncontrolled ventilation took place when the windows were smashed. Both these actions tookplace before the fire had been located.

A covering jet was not in place before the ventilation was started.

When unplanned and uncontrolled ventilation started the IC did not take into account the overalleffects of venting the bar and the development of the fire. All the factors were not properly analysedor recorded which led to an insufficient understanding and assessment of the risk.

5.2.5 There was ineffective briefing and debriefing of BA Teams to pass information about theaccess to the basement, conditions within the bar and the floor collapse, which led to aninsufficient assessment of the risk.The first three BA Teams committed to the bar were given a route to follow to the basement. Thebriefs lacked information on the location of the fire, potentially difficult access and egress, presenceof a heat barrier, potential communications difficulties and increased risk of heat stress.

The exchange of information between IC/SC and the BA Teams did not have sufficient detail withregard to conditions within the bar. Information that was passed was not used to inform the briefsfor subsequent BA Teams.

All of these factors led to an insufficient understanding and assessment of the risk.

5.2.6 The means of escape for BA Emergency Teams and successive basement firefightingcrews was not effectively maintained.The IC or SC were not informed about the existence of the emergency exit leading from the bar intothe common stair at 1 Downfield Place. If this emergency exit had been identified, any BA Teamentering the bar to gain access to or egress from the basement would have been much lessarduous due to the reduced travel distance within the bar.

The emergency exit in Sector 3 was identified early on in the incident but it was not opened untilafter FF Williamson had become trapped. Had this emergency exit been opened earlier then accessto the toilet area would have been much less demanding.

BA Emergency Teams that were committed immediately after FF Williamson became trapped didnot enter the bar with any means of firefighting. They did not have any protection from the fire otherthan a jet directed from outside the bar.

5.2.7 Ineffective cordons and control of the incident ground outside the bar.Rendezvous point, marshalling area, safe and hazard zones needed for effective control ofresources and the public were not established

In the early stages of the incident an outer cordon was set up. Hazard tape was utilised todesignate the outer cordon. From the CCTV footage, it appears that this cordon was set up tocontrol members of the public.

Throughout the incident, up to 03:21, designated inner cordon control was the BA Entry ControlBoards. Therefore, the risk area during the incident was considered to be the building. The CCTVfootage shows numerous firefighters inside the outer cordon being put at risk from smoke andflames. This could not have been considered as ‘safe air’ as defined in TB1/97 CNP 2 BA EntryControl Points.

6 6

When BA Main Control was instigated and set up there was still no appropriate method of controlfor BA wearers to pass from Main Control to individual Entry Control Points.

During the incident, at approximately 03:10, an emergency evacuation whistle was sounded. Therewas confusion on the incident ground about why the whistle was sounded and a completeevacuation of the risk area was not initiated. Operations continued with firefighters deployed into therisk area within the bar and tenement stair. After the evacuation whistle was sounded there was norole call taken to account for all personnel on the incident ground.

5.3 Organisational Underlying Causes

Statutory ResponsibilitiesLothian & Borders Fire Board (the Board) have a statutory responsibility to respond to fires, toextinguish them, and to reduce, control and to mitigate the impact of the fire and other emergencies.

The Board also has a statutory responsibility to secure the provision of the personnel, services andequipment necessary to meet efficiently all normal requirements named above.

The Board also has a statutory duty, as far as reasonably practicable, to provide safe systems ofwork for the personnel.

Lothian & Borders Fire and Rescue Service provide this provision and responsibility to dischargethese functions has been devolved down to the Chief Fire Officer.

It is the opinion of the FBU that the Board are not meeting their statutory responsibilites as detailedabove. There are underlying weaknesses in the Boards Integrated Risk Management Planning(IRMP) that need to be rectified as a matter of urgency.

To satisfy these statutory responsibilities, the Boards IRMP must be reviewed to ensure that it detailsthe outcomes they expect to achieve from responding to fires and other emergencies withinauthorities area of responsibility. Curently the expected outcomes for fires in buildings is detailed inthe SIP 2005 – 2010 as follows;

Structural firefightingWe respond to any call to a fire in a building or any other land-based structure. We will respondimmediately to any request for assistance. We will attend any call to a fire within a building orany other land-based structure within a time consistent with our existing targets.1 We willmobilise a fully capable team to each incident.2 This will be subject to internal audit and bereported on quarterly.

This does not give any information to the attending crews as to what is expected ofthem when they arrive, only that they will respond. The crews were mobilised to extinguish the fireas they were mobilised to a ‘Building Alight’. On arrival at the incident the outcomes were changedimmediately because they were faced with not only a building alight but multiple rescues requiredfrom the flats above. What is important is the definition of ‘a fully capable team’. LBFRS describesthis in the footnotes as;

2 Our definition of a ‘fully capable team’ will depend on the type of incident we are attending.Amongst other things, this will mean that we will mobilise two fully crewed appliances to all firesin buildings (where the 1985 standards of fire cover called for only one) and three appliances toa fire where persons are believed to be involved (where the 1985 standards may have called forone or two appliances).

6 7

This definition is flawed as in this incident the ‘fully capable team’ did not consist of enough personnelto adequately and effectively gain control of the incident. The initial crews were in effect dealing withtwo incident, one a fire in a basement of the Balmoral Bar, which did receive three pumpingappliances and a height appliance, the second multiple rescues from No. 1 Downfield Place whichinitially received no ‘fully capable team’. The resourses initially mobilised were not adequate and fromthe moment that the appliances arrived the incident was not and never was under control.

However, if the intial crews had been informed and understood what the expected outcomes were(as defined in the IRMP) then the Incident Commander would have immediately asked forassistance for the second incident. In fact, it was 12 minutes from the initial call and eight minutesfrom the arrival of the first appliances before further resources were requested. Even at that pointonly one further appliance was requested. It took 51 minutes from the time of the first call until ‘afully capable team’ was mobilised to the incident at 01:29 (make pumps 7) and a further sevenminutes until they attended the incident (arrival of sixth Pump, 331).

To satisfy these statutory responsibilities Lothian & Borders Fire Board must ensure that the ChiefFire Officer of Lothian & Borders FRS review the operational risk assessments for fighting fires anddealing with other emergencies to ensure they have identified all significant hazards for the systemsof work required to deliver the expected outcomes identified in the Authority’s IRMP.

To satisfy these statutory responsibilities, the Board must ensure that the Chief Fire Officer of LBFRSplans and delivers control measures for fighting fires and dealing with other emergencies to delivertheir expected outcomes in a safe manner.

These operational risk assessments must also identify control measures, as far as reasonablypracticable, to reduce the risk of the significant hazards being realised. Suitable control measuresthat must be considered are:

PlanningPlanning is the key to enhancing the safety of firefighters and others likely to be affected by FRSoperations. The IRMP of Lothian & Borders Fire Board must set standards and identify theresources required to ensure safe systems of work are maintained.

L&B FRS must assess the hazards and risks in their area relating to fighting fires in basements andrescues from height. The assessment should include other FRS areas where ‘cross border’arrangements make this appropriate.

Planning is underpinned by information gathering, much of which will be gained through inspectionsor visits by FRS personnel – for example, those covered by section 9(2)d and 10(2)d of the Fire(Scotland) Act 2005.

Information must also be gathered and used to assess the performance and review the safety ofsystems of work. Information will be available from sources both within and outside the FRS,including:• fire safety audits;• incident de-briefs;• health and safety events;• local authorities.

LBFRS must ensure systems are in place to record and regularly review risk information and toensure that new risks are identified, recorded and disseminated to operational crews as soon aspracticable.

6 8

Pre-determined responseLBFRS must ensure that the operational response to an incident will be sufficient to allow relevantsafe systems of work to be implemented. This safe system of work must be compiled using taskanalysis for all the incidents that LBFRS can reasonably foresee responding to.

This along with information received regarding the incident type and any known site specificinformation will provide a risk based assessment of the pre-determined response.

Standard operating procedureLBFRS must prepare, communicate and implement a standard operating procedure for fighting firesin basements and rescues from height, utilising the relevant GRA’s and other relevant guidancedocuments. This will identify the necessary the resources and tactics required for control measuresto be adopted by crews.

When formulating standard operating procedures, LBFRS must consider human factors followingthe principles of HSG48 (Appendix 40).

When communicating the standard operating procedure, LBFRS need to ensure personnel receive,read and understand the information.

Competence and TrainingWhen formulating a competence and training strategy FRS should consider the following points:• To enable LBFRS specific risk assessment of this incident type, LBFRS must ensure those

tasked with carrying out this assessment and developing procedures are competent;• LBFRS must ensure their personnel are adequately trained to deal with hazards and risks

associated with fighting fires in basements and rescues from height;• the level and nature of training undertaken should be shaped by an informed training needs

analysis that takes account of:– The Board’s expected outcomes for each incident type as determined by their IRMP;– The tactical plans needed to deliver the expected outcomes balanced against the

achievable outcomes with the resources available;– FRS guidance on the competency framework;– National occupational standards and any individual training needs.

Training outcomes should be evaluated to ensure that the training provided is effective, current andit meets defined operational needs as determined by the Board’s IRMP to ensure consistency andinteroperability across FRS boundaries.

Command and ControlThe Incident Commander should follow the principles of the current national incident command system.

Prior to committing personnel into any hazard area, the Incident Commander must take account ofthe actual information available regarding the incident at the time. This will assist them to makeeffective operational decisions in what are recognised as sometimes dangerous, fast moving andemotionally charged environments. Incident Commanders will need to consider the outcomesexpected by the Board’s IRMP against the achievable outcomes with the resources available.

A thorough safety brief prior to deployment of personnel within the hazard zone should be carried out.

Communication of new or changed risks should continue throughout the incident.

Incident commander must ensure adequate supervision of personnel in development.

6 9

5.3.1 ResourcesLothian and Borders Fire Board have not identified the types of emergency they will respond to orthe expected outcomes from their response within their IRMP

LBFRS have not planned their response requirements for the outcomes expected within L&B FireBoard IRMP.

The types of emergency at this incident were:• A fire in a basement, and;• Multiple rescues from a house of multiple occupation of persons suffering smoke inhalation.

LBFRS had not carried out a task and sequence analysis of these two types of emergency and hadfailed to plan and apply the resources required to extinguish fires, carry out rescues and reducecontrol and mitigate the effects of fire at this incident. LBFRS mobilises appliances withoutconsideration for the number of personnel required.

The resources sent were not adequate and human error was an inevitable consequence of thesefailings.

Control Operators did not communicate all the available information to the incident ground

Control Staff received information from Police Control which identified cylinders may be present inthe premises. This was not communicated to the incident ground.

Control Operators identified that Stage 2 ECP required the mobilisation of a further pumpingappliance.

On receipt of the ‘Stage 2 Entry Control Procedures’ message at 00:48, Control Operatorsimmediately identified that an additional pumping appliance was required. This is to allow additionalfirefighters to provide a relief and/or emergency team (as detailed in TB1/97 CNP6 Stage 2Procedures). The first emergency team was not requested and assembled until 01:28.

This indicates that on the incident ground there was an insufficient understanding of TB1/97 and theeffect that increasing the BA Control to Stage 2 would have.

There was confusion on the incident ground about the attendance of the 5th pumpingappliance (502).

A message was sent at 01:25 requesting confirmation of the attendance of the 5th pumpingappliance (502). The 5th pump was in attendance at 01:03 and the crew had already beendeployed in BA into the bar. This shows confusion on the incident ground with regards to availableresources and insufficient management of the resources already allocated to the incident.

There was confusion around the number of pumps required after the BA Emergency wasdeclared.

On receipt of the BA Emergency message (01:34) Control mobilised an additional pumpingappliance. When the IC requested ‘make pumps 9’ (01:54) the Control Operators were unsurewhether the 9 pumps included the BA Emergency pump. The fireground was not informed byControl that an additional pump had been mobilised for the BA emergency. The confusion resultedin a delay of approximately 4 minutes before the 9th pump (392) was mobilised.

7 0

The mobilisation of FDS Officers to incidents takes no account of their geographical location.

The first Officer to be mobilised to the incident (00:53) was FDS Officer 30, who was initiallydesignated as Incident Commander. FDS Officer 30 was the 3rd Officer in attendance (01:22) dueto the escalation of the incident and the mobilisation of additional Officers. Once in attendance FDSOfficer 30 role was changed to Command Support Officer. The reason that it took 29 minutes toattend was solely due to the geographical location that the Officer mobilised from. This had thepotential to compromise the Command Structure on the incident ground due to the time for FDSOfficer 30 to arrive at the incident.

On the incident ground there was no identification of Firefighters in development phase of theirtraining.

At the incident, there were several Firefighters in the development phase of their training. On at leastone occasion during the incident two Firefighters in the development phase of their training werecommitted into the bar as a BA Team. It is not possible for the IC or SC to visually identifyFirefighters in development.

5.3.2 ProceduresLothian and Borders Fire Board have not clearly identified the types of emergency they will respondto or the expected outcomes from their response within their IRMP

LBFRS has not planned their response requirements for the outcomes expected within the Board’sIRMP.

The Board and the FRS have not carried out suitable and sufficient assessment of risk for the typesof emergency they respond to. Significant hazards do not have adequate controls. Instead LBFRSrely on the Incident Commanders judgement using dynamic risk assessment. The impacts ofhuman error on work practices are well known. Lack of suitable and sufficient control measuresmade human error at this incident inevitable.

Despite the national guidance being revised and reissued in 2008, LBFRS have not updated theIncident Command and Control procedures since 2006.

The current LBFRS Incident Command and Control System is based on the guidance containedwithin Fire Service Manual Volume 2 ‘Fire Service Operations – Incident Command’ (Second Edition– Revised 2002). The national guidance was updated in 2008 with the issue of Fire Service ManualVolume 2 ‘Fire Service Operations – Incident Command’ (Third Edition – Revised 2008). The ORAMsystem has failed to identify the introduction of the new guidance and no changes have been madeto the ICCS.

There is no individual FOP for compartment fires, basement fires or for tactical ventilation.

The FOP’s are the FRS safe system and should address the risk areas highlighted in the publishedGeneric Risk Assessments (GRA) in Fire Service Guide Volume 3 – A Guide to Operational RiskAssessment. LBFRS FOP 3.1 which covers ‘Fighting fires in buildings’ has been copied from thepublished GRA. There has been no assessment of the specific risks that are relevant in LBFRS area.The guidance document states ‘It is imperative that brigades use these assessments as part of theirown risk assessment strategy not as an alternative or substitute for it. They are designed to helpbrigades assess their own risks, so they should be included in the brigade's normal planningprocess.’

7 1

This resulted in the incident being managed in a generic fashion without due consideration to theunique circumstances found in basement fires, the additional significant risk to firefighterscommitted to the basement and the effects that ventilation would have on the development of thefire.

There is only electronic access to FOP’s and other LBFRS procedures. There is no paper basedsystem on fire stations to allow all firefighters unrestricted access to LBFRS documents

All FOP’s and other procedures should be easily accessible to all uniformed staff.

There is limited access to national guidance contained within Fire Service Manuals, Guide toOperational Risk Assessment Volume 3 and Technical Bulletin TB1/97

A number of the critical documents produced by LBFRS refer to publications which are not readilyaccessible to operational staff, particularly at stations.

5.3.3 TrainingLBFRS Training Policy and associated Annexes do not clearly define the responsibilities of eachline manager in delivering training to operational personnel.

LBFRS Training Policy BO F1 (Introduced 1999) is out of date and the ways that training isdelivered, assessed and recorded have now changed.

LBFRS Training Policy BO F1 does not define the responsibilities appropriately. The delineation ofresponsibility in terms of the different categories of training (BO F1 Annex 1) is unclear.

There is no reference in any of BO F1 and related Annexes of the training requirements,responsibilities, assessment and verification of roles above WM.

Documents referred to within the Training Policy are not readily available on stations.

The Training BO F1 and associated Annexes refer to a number of documents listed below:• JTC Report “Fire Service Standards”; • JTC Guidance “A best practice for assessment” (Central Fire Brigades Advisory Council);• Training for hazardous occupations HSE OP8;• FSC 3/1996 Principles of Operational Training;• Scottish Fire Service guides to health & safety.

The objectives of continuation training are not clearly defined.

Continuation training for Watch Managers is not provided or delivered effectively.

BO F1 Annex 12 sets out how uniformed staff up to the role of WM are assessed and verified. It isaccepted that station based uniformed staff will be trained by the management team on individualwatches using a cascade system, i.e. WM trains CM, CM trains FF. This does not accommodatethe training needs of the WM where it is not possible for the cascade system to operate.

Although the table sets out that Watch Commanders are assessed by Station Commanders theGM responsible for any particular station is not normally involved in routine operational continuationtraining for the WM’s. In reality the WM is responsible for planning and delivering training forthemselves.

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Support for delivery of station based training is poor and provision of training facilities and offsite locations is not managed effectively.

Materials provided by the Training Function, supported by the Scottish Fire Services College, arecomputer packages. There is limited support for stations from the Training Function and the deliveryof station based training is left to the watch management

When arranging offsite training, there is no Training Function coordination between watches orstations. Opportunities for operational staff to train in different venues and locations are limited.

Provision of hot fire training is not managed effectively to ensure that all operational personnelattend on at least one occasion throughout the training year.

BO F15 (Revised) details the Wholetime and Retained Breathing Apparatus Training for LBFRS. Thisdocument states;

1.2 All wholetime personnel will attend one of the above specified locations for Breathing ApparatusTraining on an annual basis.

The document makes no reference to the breathing apparatus training for uniformed staff who donot work on fire stations.

The training is not managed effectively which has resulted in a large percentage of uniformed staffnot achieving the aims set out in FSC 17/1970. This has happened consistently over a number ofyears.

There is no regular structured training for fire behaviour.

There is currently no provision for training for fire behaviour.

There is no regular structured training for ventilation.

There is currently no regular structured training for any type of ventilation.

Continuation training for ICCS Level 2 training of Watch and Crew Managers is not effectivelymanaged.

There is limited opportunity for WM and CM to access ICCS training. The training is self study.Structured training is provided annually when WM and CM attend BA continuation training.No continuation training on the practical application of command responsibilities is provided onstation for WM.

Continuation training for ICCS Level 3 and above is not effectively managed.

No continuation training is provided for WM, GM and AM for level 3 incidents and above.

Recording of training using PDR Pro computer system is generic.

PDR Pro is only used by wholetime firefighters based at fire stations. The Information recorded is notspecific to the task carried out by the individual. As an example, one CM recorded 68 different rolesor sub roles performed at an incident.

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The PDR Pro system is based on generic actions performed. The way that information is recordedon the system makes it is difficult to analyse what task each individual performed at the incident ortraining event.

Training for the use of PDR Pro is not effective.

There is no structured training for the use of PDR Pro. This has resulted in training being recorded indifferent ways which has caused difficulties in accessing and auditing the information.

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6 Recommendations

OPERATIONS FUNCTION

Recommendation 1Statutory ResponsibilitiesTo satisfy the statutory responsibilities, Scottish Fire Board must ensure that the Chief Fire Officer plans anddelivers control measures for fighting fires and dealing with other emergencies to deliver their expectedoutcomes in a safe manner. Those plans should be published in the National Risk Reduction Strategy andreviewed annually.

Recommendation 2Rotation of Breathing Apparatus (BA) crewsThe FRS must introduce a safe system of work to ensure that firefighters have suitable and sufficient periodof recovery between BA wears. For BA activities in ambient temperatures the recovery period should be atleast 28 minutes. This should be extended to at least 65 minutes for hot fire environments.

The safe system of work must also include a method of ensuring and recording that all BA wearers haveconsumed at least 1000ml of water before they are recommitted.

Recommendation 3Procedures for fighting fires in basementsThe FRS should introduce specific written guidance for dealing with fires in basements. The guidance shouldbe in the form of an appropriate Framework Operational Procedure. This should relate specifically tofirefighting in basements and should examine the hazards, risks and control measures applicable to suchincidents.

Recommendation 4Emergency Evacuation whistle and roll callThe FRS should establish appropriate procedures to be followed in the event of serious and imminentdanger on the incident ground.

The FRS should introduce an emergency evacuation procedure whilst at operational incidents. Theprocedures must include a roll call to ensure that all personnel are accounted for and have withdrawn fromthe risk area.

Recommendation 5BA Emergency proceduresIn the event of a BA Emergency, the FRS should introduce a method of standardising information sent toControl in order to ensure that the appropriate resources are mobilised to the incident.

Recommendation 6ICCS Officer MobilisationAs this is an emergency response, the FRS should introduce a method of mobilising the nearest availablecommand officers to the incident.

Recommendation 7Information exchange on incident groundThe FRS should introduce a detailed guidance on briefings and debriefings of BA Teams.

7 5

Recommendation 8Identification of Firefighters in developmentThe FRS should introduce a visual indicator that identifies Firefighters during the development phase of theirtraining on the incident ground.

TRAINING FUNCTION

Recommendation 9PDR Pro system reviewThe FRS should introduce a system for recording training for all roles and all duty systems. The recordingsystem should accurately reflect the activity undertaken and identify any training requirements. All therecorded information needs to be easily accessible.

Recommendation 10Cordon training and guidanceThe FRS should introduce suitable and sufficient training and guidance on the implementation andmaintenance of Rendezvous Points, Marshalling areas, inner cordons and cordon control of hazard and safezones.

Recommendation 11Fire behaviour and tactical ventilation trainingThe FRS should introduce a programme of fire behaviour training which includes maintenance of skills. Thisprogramme must include reference to tactical ventilation.

Recommendation 12Review training policyThe FRS should review the training policy Brigade Order F1.

Recommendation 13Analytical Risk Assessment training and guidanceThe FRS should introduce a training programme for the concept and application of analytical riskassessment.

COMMUNITY SAFETY

Recommendation 14Fire Safety in premises with basementsThe FRS should introduce operational risk assessment for commercial premises with basements. Theassessment process should utilise relevant information held by other agencies and should also considerfamiliarisation of operational crews. This assessment should be recorded.

7 6

7 References

Appliance call signs, mobilisation time and time in attendance(In chronological order)

301 – Tollcross WrL/ET Mobile: 00:41 In Attendance: 00:42

302 – Tollcross WrT Mobile: 00:41 In Attendance: 00:42

303 – Tollcross TTL Mobile: 00:43 In Attendance: 00:43

311 – Sighthill WrL/ET Mobile: 00:43 In Attendance: 00:45

564 – Fire Investigation Unit Mobile: 00:53 In Attendance: 01:13

512 – Crewe Toll WrT Mobile: 00:53 In Attendance: 00:59

364 – Major Incident Unit Mobile: 00:53 In Attendance: 01:05

325 – Command Support Mobile: 00:53 In Attendance: 01:03

502 – McDonald Road WrT Mobile: 00:58 In Attendance: 01:03

86 – Tollcross BA Support Vehicle Mobile: 00:58 In Attendance: 01:03

524 – Marionville Incident Support Unit Mobile: 00:58 In Attendance: 01:07

331 – Dalkeith WrL/ET Mobile: 01:31 In Attendance: 01:36

511 – Crewe Toll WrL/ET Mobile: 01:32 In Attendance: 01:39

501 – McDonald Road WrL/ET Mobile: 01:41 In Attendance: 01:47

312 – Sighthill WrT Mobile: 01:56 In Attendance: 02:00

392 – Peebles WrT Mobile: 01:58 In Attendance: 02:08

381 – West Linton WrL/ET Mobile: 02:12 In Attendance: 02:43

541 – Bathgate WrL/ET Mobile: 02:13 In Attendance: 02:28

544 – Bathgate Incident Support Unit Mobile: 02:17 In Attendance: 02:27

7 7

Appliance Crews

301 WM FF FF FF FF

302 CM FF FF FF E Williamson

303 CM FF

311 WM FF FFFF FF

564 WM CM

512 CM FF FF FF

364 CM FF

325 CM FF FF FF

502 CM FF FF FF

86 FF

524 CM FF

331 WM CM FF FF FF

511 WM FF FF FF FF

501 WM FF FF FF FF

312 CM FF FF FF

392 CM FF FF FF

381 CM FF FF FF FFFF

541 WM FF FF FF FF

544 CM FF

7 8

11234

156

27

2891011

33

4121314

515

6161718

7192021

22

923

410

242526

527282930

631323334

11353637

12383940

134142434445

1446474849

1550

Officers call signs, mobilisation time and time in attendance(In chronological order)

Call Sign 30 Informed: 00:47 Mobile: 00:53 In Attendance: 01:22




Call Sign 20 Informed: 01:00 Mobile: N/A In Attendance: N/A



Call Sign 75 Informed: 01:32 Mobile: N/A In Attendance: 01:48

Call Sign 01 Informed: 02:07 Mobile: N/A In Attendance: 03:19

30 GM(A)

12 GM(B)

50 GM(A)

06 GM(A)

20 GM(A)

02 ACFO

11 Temporary AM

75 GM(A)

01 CFO

7 9

123451

16

1

Breathing Apparatus Teams

BA Team 1 FF FF Ewan Williamson

BA Team 2 FF FF

BA Team 3 FF FF

BA Team 4 FF FF

BA Team 5 FF FF

BA Emergency Team 1 FF FF

BA Emergency Team 2 FF FF

BA Team 6 FF FF

BA Team 7 FF FF

BA Team 8 FF FF

BA Team 9 CM FF

BA Team 10 FF FF

BA Team 11 FF FF

8 0

1

1

3

3

5

810

12

13

14

19

20

21

1025

2730

3133

34

3537

32

4245

BA duration tables

Technical Bulletin TB1/97

Consumption of air formula

Open circuit apparatus1. A table showing the remaining working duration of open circuit BA can be calculated for any

cylinder pressure by using the following formula:

P x CD = -10

N x 40

Where:

D = the remaining working duration (in minutes)

P = the pressure in the cylinder (bar)

N = the maximum filled pressure of the cylinder (bar)

C = the capacity (in litres) of the cylinder when pressurised to 'N' bar

The figure 40 used in the calculation represents the notional consumption rate used in estimatingthe average consumption of an open circuit apparatus and approximates to a wearer walking ata speed of 6 km/hour. The figure 10 represents the period allotted to the Safety Margin of theapparatus in minutes.

LBFRS use breathing apparatus cylinders with a capacity of 1800 litres of air. The following table isstandard on all Entry Control Boards in use within LBFRS and is taken from The Fire Service TechnicalBulletin 1/97.

Calculation of the time FF Williamson Time of Whistle (TOW)

Cylinder Pressure – 200 (As recorded on recovered BA Tally)

Time of Entry – 01:17 (As recorded on recovered BA Tally)

200 BAR = 35 minutes of air until TOW – Calculated TOW = 01:52

8 1

First Entry 1800LITRES

Pressure in bars 200 190 180 170 160

Time in minutes 35 33 30 28 26

Re-entry

Pressure in bars 150 140 130 120 110 100 90

Time in minutes 23 21 19 17 14 12 10

Abbreviations

ACFO Assistant Chief Fire Officer

ADSU Automatic Distress Signal Unit

AM Area Manager

BA Breathing Apparatus

BO Brigade Order

CFBT Compartment Fire Behaviour Training

CFO Chief Fire Officer

CLG Communities and Local Government

CM Crew Manager

COPFS Crown Office Procurator Fiscals Service

CSU Command Support Unit

ECB Entry Control Board

ECO Entry Control Officer

ECP Entry Control Point

ERI Edinburgh Royal Infirmary

FDS Flexi Duty System

FF Firefighter

FIU Fire Investigation Unit

FOISA Freedom of Information (Scotland) Act2000

FOP Framework Operational Procedure

FSC Fire Service Circular

GRA Generic Risk Assessment

GM Group Manager

HRJ High Pressure Hose Reel

IC Incident Commander

ICCS Incident Command and Control System

ISU Incident Support Unit

LBFRS Lothian and Borders Fire and RescueService

LBP Lothian and Borders Police

LSO Logistical Support Officer

MIU Major Incident Unit

OIC Officer in Charge

ORAM Operational Risk Assessment Model

PDA Pre determined attendance

PPE Personal Protective Equipment

RSJ Rolled Steel Joist

S&R Search and Rescue

SC Sector Commander

SFRS Strathclyde Fire and Rescue Service

SIFTC Scottish International Fire Training Centre

SIP Service Improvement Plan

T/AM Temporary Area Manager

TB 1/97 Technical Bulletin 1/97

ToW Time of Whistle

TTL Turntable Ladder

WM Watch Manager

WrL/ET Water Tender Ladder/Emergency Tender

WrT Water Tender

ZF LBFRS Control Room radio call sign

8 2

8 Appendices All appendices are on the disc accompanying this report.

Appendix Details Status

1 Photographs of Sectors 1, 2 & 3 Included

2 Premises plans Included

3 Photographs – LBFRS taken during incident Included

4 Photographs – LBFRS taken later 12th July 2009 Included

5 Photographs – FBU taken 12th July 2009 Included

6 Photographs – FBU taken 7th October 2009 Included

7 Photographs – FBU taken 31st May 2010 Included

8 Letter from HSE – PPE EW (Worn at the incident) Included

9 BTTG Report – PPE EW Second set testing report Included

10 BA Set Report – COPFS Report not releasedfrom CoPFS

11 BTTG Report – PPE EW (Worn at the incident) Report not releasedfrom CoPFS

12 LBFRS Incident Log Included

13 LBFRS Framework Operational Procedure 3.1 Included

14 LBFRS Incident Command & Control Pt1 & Pt2 Included

15 Brigade Order F1 – Training Policy Statement Included

16 Brigade Order F1 – Annex 1 Included






22 Brigade Order F15 – Wholetime and Retained BA Training Included

23 Operational Refresher Training Course 2009/2010 Included

24 Mobilisation message Included

25 LBFRS Service Improvement Plan 2005-2010 Included

26 LBFRS Performance Plan 2007 Included

27 LBFRS Performance Plan 2008 Included

28 LBFRS Service Plan 2002 Included





8 3

9 Sources

End Note Details

1 HSG48 – Reducing Error and Influencing Behaviour

2 Death Certificates

3 TB1/97

4 Interview Transcripts

5 Personal Statements

6 Control Room Recording Transcript

7 Training Records

8 CLG Report – Core Temperature, Recovery and Re-deployment during a Firefighting,Search and Rescue Scenario, Fire Research Technical Report 18/2008

9 Fire Service Manual, Volume 4, Fire Service Training, Guidance and ComplianceFramework for Compartment Fire Behaviour Training (CFBT)

10 Dynamic Management of Risk – Fire Service Guide

11 Fire Service Manual – Volume 2 – Fire Service Operations – Compartment Fire andPractical Ventilation

12 The term ‘fully capable team’ is described in LBFRS service improvement plan 2005-2010(Appendix 25)

13 Physiological Assessment of Firefighting, Search and Rescue in the Built Environment,Fire Research Technical Report 2/2005

14 Dynamic Management of Risk at Operational Incidents

15 FFR 18-2008

8 4

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