Cuts and lack of training led to the deaths of two firefighters in Hertfordshire, the Fire Brigades Union says in its comment following the completion last week of the inquest into the fatalities at Harrow Court, Stevenage.
Matt Wrack, FBU general secretary, said: ‘We have heard of the extraordinary acts of courage and bravery shown by everyone at this tragic fire in Stevenage.
‘In particular the bravery and courage shown by Mike Miller and Jeff Wornham who rescued one person but died trying to save the life of Nathalie Close.
‘Everyone at this incident did the very best they possibly could with the resources, training and equipment available to them.
‘But initially there were not enough firefighters to tackle this fire safely and none of them had specific and practical training in fighting fires in high rise blocks.
‘The FBU investigation concluded that Hertfordshire fire authority did not put in place what was needed to allow their fire crews to fight this fire safely.
‘Fire crews work in difficult, challenging and potentially very dangerous situations which require the highest standards of operational training and preparation and those were lacking.
‘Selfless and courageous people act in selfless and courageous ways to save life.
‘It is essential to avoid placing firefighters in situations where the instincts which make them firefighters push them into attempting rescues short-handed, without adequate training and without the water they needed to suppress the fire.
‘The FBU investigation concluded that Hertfordshire fire authority failed to put in place proper procedures, did not have adequate training and did not send enough firefighters in the initial response to tackle this fire safely.
‘But this tragic loss of life could have happened in any number of fire authorities across the UK, it was only by misfortune that it happened in Stevenage.
‘There are three families whose lives will never be the same because of what happened at Stevenage on that night.
‘Mike and Jeff’s colleagues will also live with what happened all of their lives.
‘The entire fire service and government need to learn the lessons of what happened in Stevenage.
‘There must be an end to the constant pressure to cut frontline fire crews and cut corners with training and other safety critical activities.
‘In organising their response to potentially very dangerous incidents, fire authorities cannot be allowed to cut corners.
‘Cuts cost lives and we do not intend to lose any more people in this way.
‘We look forward to reviewing the Coroner’s Rule 43 report on the incident which he has promised to send to the relevant bodies in the fire service and government.’
In its executive summary, the FBU Health and Safety investigation report states:
‘It was the opening of the front door to Flat 85 that gave rise to the rapid manifestation of whichever fire phenomenon that did then occur.
‘Given this common area of agreement, it can be concluded that had Ff Wornham and Ff Miller not opened the front door at the exact time that they did, then the fire phenomenon is unlikely to have occurred at the time that it did and the two Firefighters would not have been exposed to its fatal effects.
‘This being the case, the FBU believes that establishing the cause of their deaths has less to do with the precise definition of the fire phenomenon that occurred and more to do with those factors that led to Ff Wornham and Ff Miller opening the front door when they did and without the necessary water, resources or personnel they required.’
The summary says: ‘This comprehensive report is divided into specific sections and sub-sections but the areas of organisational weakness can be summarised as falling into three main categories:
Standard Operating Procedures (SOPs), Training and Emergency Response Resources.
Standard Operating Procedures
‘The investigation identified many organisational weaknesses in the development, monitoring and review of Standard Operating Procedures.
‘In particular, the High Rise Incident Procedures were wholly inadequate and failed to take account of recommendations following the HSE Improvement Notice awarded to the Strathclyde Fire Board; the Breathing Apparatus Procedures failed to satisfy the provisions of national guidance issued by Her Majesty’s Inspectorate; and the Incident Command Procedures were inadequate and omitted many provisions contained in the national guidance issued by Her Majesty’s Inspectorate.
‘The FBU considers these Standard Operating Procedures produced by Hertfordshire Fire & Rescue Service (HFRS) were inadequately drafted, monitored and reviewed and as a result, were not fit for purpose at the time of the Harrow Court Incident.
Training
‘The investigation identified serious inadequacies in the provision of training for the Hertfordshire Firefighters that attended the Harrow Court incident.
‘The circumstances and events of the Harrow Court Incident on 2nd February 2005 exposed wider concerns of the apparent under-provision of training in HFRS.
‘Between them, it is apparent that the Firefighters and supervisory officers in the initial attendance at Harrow Court had received insufficient formal Incident Command training, Crew Command training, Dynamic Risk Assessment training, Breathing Apparatus (heat and smoke) Refresher training and separately dedicated, practical and theoretical Compartment Fire Behaviour training to deal safely and effectively with the situation they were confronted with.
‘Specifically, the FBU notes the lack of practical attack training for compartmental fires.
‘In addition, it is clear that any basic awareness of High Rise Incident procedures was not sufficiently underpinned with practical High Rise Incident training at either the Training & Development Centre or at fire stations.
‘The Firefighters were unfamiliar with the premises and the likely risk they would encounter in an emergency, as they no longer carried out 1(i)(d) inspections on these types of premises.
‘The deficiencies in training exposed by the Harrow Court incident seem to betray an apparent and endemic organisational weakness in the provision of training in many other operational areas of firefighting.
‘Predominantly, this seems due to a lack of strategic emphasis, planning, monitoring and review by senior managers of actual training undertaken and insufficient resource allocation.’
The FBU report stresses: ‘The resource increases necessarily include the need for additional instructors to deliver, monitor and review training and the maintenance of sufficient staffing levels at fire stations to afford firefighting personnel the amount of dedicated training time their safety deserves.’
Emergency Response Resources
‘The FBU Investigation identified serious organisational weaknesses in the identification, assessment and inspection of actual High Rise risks; serious organisational weaknesses in the systematic
assessment, monitoring and review of standard operating procedures to respond to compartment fires within actual High Rise risks; and insufficient provision of emergency response resources to form the initial attendance for compartment fires in High Rise risks such as Harrow Court.’
The FBU calls for a ‘review of the HFRS Integrated Risk Management Plan such that the initial attendance of emergency response resources for High Rise Incidents ensures a minimum of 13 Firefighters arrive in sufficient time of each other to enable all of the service’s safe systems of work to be implemented in full at the outset and without endangering Firefighters due to a delay in their arrival.’
The report adds: ‘The FBU firmly believes that HFRS failed to ensure their standard operating procedures (SOPs) were fit for purpose; failed to ensure the application of the SOPs were systematically and practically trained for; and failed to ensure that sufficient personnel were mobilised for deployment on the initial pre-determined attendance (PDA) to allow the immediate, safe and effective implementation of the applicable SOPs.
‘The FBU applauds the courage shown by all the HFRS firefighting crews that attended the Harrow Court incident in the small hours of 5th February 2005.
‘In particular, the selfless and courageous actions of Ff Wornham and Ff Miller were immense given the circumstances they found themselves in.
‘The key questions are:
‘Would the fatalities of Ff Wornham and Ff Miller have been prevented had HFRS ensured adequate procedures, training and resources were systematically in place?
‘Almost certainly!
‘Would the life-threatening risks faced by the Firefighters at the Harrow Court incident have been significantly reduced had HFRS ensured adequate procedures, training and resources were systematically in place
‘Without doubt!’
