Marston Road, Stafford Incident Case Study INTRODUCTION The presentation that is about to be shared with you has been put together following a serious house fire that occurred in Staffordshire in Sept 2013. The aim is to share with you the lessons that have been learnt following an investigation into what we at SFRS are classing as “near miss” Brian Griffiths Operational Assurance Manager

Introduction Staffordshire Fire & Rescue Service recognises the potential for this event to have led to the serious injury or death of firefighters The Service was determined to examine the events to identify, share and implement any learning points in an open and honest manner to ensure firefighters can operate as safely as possible in the future Although SFRS classed as NEAR MISS .. This incident had the potential to cause serious injury or even death to 4 x FFs All those involved in the investigation - have been open and honest with their account of the events, we can all learn from their experiences and share the lessons learnt.

Incident Safety Event Case Review NATURE - House full of smoke ADDRESS - 93 Marston Road, Stafford DATE - 9th September 2013 TIME - 12:00hrs ATTENDANCE – PRL Stafford WRT Rising Brook Background Property Type – Victorian - note the windows/wall and railings Occupancy – Family of three, Middle aged couple, Nature…… House full of smoke Attendance- 1 x Wholetime crew and 1 x retained crew ; both Crews deemed confident and competent. IC had spent 3yrs+ as a training school CFBT Instructor

In Attendance – 12:06hrs Info Gathering; MDT, Occupier in attendance, No life risk, Property type, light smoke issuing The Brief – 2 x BA, 1 HRJ, TIC, search, locate & extinguish the fire. INFO GATHERING - Upon arrival the occupier and his son had evacuated the property. The occupier appeared to be very vague and not forthcoming with information but he did inform the IC that the house was full of smoke. He had no idea what was on fire. All persons accounted for, however the pet dog may still be in the house. The IC completed a 360 degree appraisal of the property. THE BRIEF - based upon the information available to him at the time, the IC deemed this to be a “saveable property” and therefore committed 2 x BA with 1 x HRJ, & TIC to locate and extinguish the fire. ACTION OF BA CREWS - Crew 1 ( Stafford); entered via front door took a left had search, entered the front lounge. Witnessed room full of thick smoke, very hot, but no sign of fire. The TIC was used but it “ WHITED OUT” - Described the floor as “ spongy/springy” They left room and continued along the hallway and entered the rear lounge; light smoke but again no sign of fire. They left this room and entered the rear utility room, no sign of fire. Back in the hallway then radioed through to the BACO to inform the IC what they had discovered and asked if there was a cellar? – NO RESPONSE FROM BACO, NO RADIO ACKNOWLEDGEMENT. They were then met by BA crew 2 ( Rising Brook) in the hallway and both crews decided to proceed to the first floor to search for the fire. BA 2 discovered a dog on the landing of the first floor, passed it to BA crew 1 on the stairs who then carried the dog outside to fresh air. They then re-entered the property and again proceeded to the first floor. The IC was unaware that the dog had been rescued. At this point both BA crews described the conditions as – VERY LOW NEUTRAL PLANE, EXTREMELY HOT, FELT A RAPID RISE IN TEMP, SAW AN ORANGE GLOW FOLLOWED BY AN EXPLOSION. Both crews were blown backwards and off their feet.

Sequence of Events 12:06hrs - Staff PRL INAT ( 6mins) 12:12hrs - Informative “Heavy Smoke Logging 2 BA Offensive Tactics. ETA of Rising Brook? 2 BA to be ready and covering jet required on arrival.” 12:14hrs - Rising Brook INAT 12:16hrs - Tac Advisor INAT 12:18hrs - Make pumps 4 12:21hrs - EXPLOSION OCCURS !

Question - If both crews were deemed as competent and experienced in dealing with this type of incident and SFRS has learnt from previous, tragic incidents ( Coroners Rule 43s) why were 4 BA wearers caught in a severe backdraft? SO WHAT WENT WRONG ?

Your Initial thoughts ? View CCTV. Just before we play the CCTV footage of the incident can I ask you all to consider a few questions throughout the presentation:- Could this event happen within your organisation today? Has this type of event occurred within your organisation? Would you know if it had? What did you do about it? Are you entirely confident that you organisation provides adequate training and equipment for your fire-fighters and supervisory officers to deal with these types of incident? CCTV TIMINGS – 12:06-08secs - Staff PRL arrives at Scene 12:09-05secs – covering jet out, smoke issuing from doorway. 12:12-48secs - BA crew 1 briefed and about to enter, 12:21-05secs - Make pumps 4 sent 12:21-27secs - Smoke thickens, pressurises, changes colour 12:21 -42secs – IC & TA agree to withdraw crews, 12:21-45secs - BACKDRAFT OCCURS – simultaneous BACO hits Board Evac 12:22- 20secs - Crews Withdraw

External indicators – thick, black smoke BA crews experience rapid temp rise. IC & TA decide to withdraw crews ECO hit the “ board evacuation” Explosion Occurs IC considers “ BA Emergency” Crews emerge from property - 20secs later 15mins from In Att - Rapid Changes Occurred 21secs BA crews reported that within approx 20secs: a rapid rise in temp Neutral plane drops significantly Bright orange glow “fire kit felt like it was on fire!” shock wave Blown off their feet BA crew 2 at top of stairs emerge from property FIRST ( step over BA 1)

What caused the explosion? The Fire Research Establishment have confirmed a backdraught did occur within the property This is possibly the first incident in recent years where firefighters have been caught in a backdraught and serious injuries or fatalities have not resulted The CCTV and the Crew statements were sent to the Fire service college MiM Fire Research Establishment for analysis to verify what caused the explosion, (Fire Gas explosion/ flashover/ Backdraft or other) The Fire Research Establishment have confirmed a backdraught did occur within the property

+ 4 ? Blaina Atherstone Leos Store, Avon Harrow Court Shirley Towers Oldham St Manchester Marlie Farm Lets just remind ourselves of a few incidents that have occurred over the years where we've all learnt lessons following the tragic loss of some of our colleagues Following the incident at Marston road, this figure could have quite easily increased to 20, 21, 22 or even 23! In the last 20 years - 19 Firefighters (UK) have lost their lives at fires

Rule 43s FF fatalities should not be the catalyst for change SFRS have conducted a Gap analysis of Rule 43s from National incidents such as the ones previously mentioned. Gaps identified in:- Training ( ICS1 and BA entanglement) Equipment ( PPV, BA mods, Wire Cutters) Procedures ( High Rise policy) Risk Information (PORIS) Liaison with Local Authority Building Control WHY WAIT FOR RULE 43s – lets learn from ALL incidents FF fatalities should not be the catalyst for change SFRS recognise that may have not correctly disseminated the lessons learnt from Rule 43s their before the Marston Road Incident occurred - Now, we SFRS have adopted a more pragmatic to communicating lessins learnt. EGs of what we have done:- TRAINING - ICS 1 Courses -- compulsory that all our FFs attend; risk appetite/perception - BA Practical refresher courses - cable entanglement training OPERATIONAL ASSURANCE Rule 43 of the Coroners Rules   Rule 43. Rule 43 provides that if, at an inquest into a person’s death, a coroner hears evidence that “gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist in the future; and in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances” the coroner may report the circumstances to whoever may be able to take remedial action. There is an obligation on the person receiving the report to respond formally to the coroner and in that response details must be given of what action is being taken or an explanation provided of why no action is proposed. The power is a very valuable one in helping ensure that lessons are learned - which is often a driving concern of the families of victims in many inquests.

Learning Outcomes Information Gathering – Active Questioning/ Thermal scanning Information Exchange – Risk Critical Information Impact on crews and the OIC - Debrief and Investigation INFO GATHERING- During the incident the gathering of information from the occupier and from external signs was very difficult. Occupier was shocked and vague. ACTION – Training for all CM/WMs in active questioning of the owner/occupier to included the property layout and fire loading for domestic properties. The service has issued new TICS THERMAL SCANNERS which have the ability to record images and can externally, thermally scan a building. (£90k) Training - OIC to conduct THERMAL SCANNING as part of his 360 appraisal to inform his decision making. LOCATE THE FIRE FROM OUTSIDE OF PROPERTY PRIOR TO COMMITTING CREWS --------------------------------------------------------------------------------- 2) COMMS - BA teams entered the building and had risk critical information which needed relaying to the ECO & IC . The information was never received and could have been a factor in the crews still being in the risk area when the Backdraught occurred. SPONGY FLOOR – IS THERE A BASEMENT? – WE ARE NOW CHANGING LEVEL? The crews had an opportunity to communicate face to face when they removed the dog to fresh air but they didn’t? - The IC has stated that if he had received this information he would have changed his tactics and considered withdrawing the crews at this point! ACTION Additional radios now issued to all appliance’s to ensure that all crews entering the risk area have communications If the BA crew do not get a response or acknowledgment from BAECO they must withdraw from the risk area to ensure the message is passed and communication’s are checked ( is this a cultural issue?) BA / Core skills / ICS training to include: DRA – Individuals to constantly review; Risk Maxims - LIFE/PROPERTY Crews to take ownership of critical decisions NEW BA NOG – “ individuals need to carry out their own DRA, dynamics change , CONSIDER MAXIMS, make decisions, its ok to withdraw!!! _____________________________________________________________________________ 3) IMPACT ON CREWS - many different people wanted to ask questions of the crews - Health and Safety, Fire Investigation and officers undertaking the investigation into the events of the day. This meant the crews answering the same question over and over again adding to the stress and trauma. ACTION:- A review of the debrief policy and Trauma Risk Management Policy (TRiM) to include guidelines of how a team should be assembled and to be able to ask the question once and use the information may times. Consider specific guidance for the role of Liaison / Welfare Officers.

Training Outcomes Competency Framework – SFRS advancement Programme now gives us a structure to deliver all underpinning knowledge for operational crews through the IFE. Fire Behaviour Training – search (TIC) locate & extinguish fire, Practical application of water, ( New BA Ops Guidance, Part B - ) 4) TRAINING – ACTION - Training for Risk/Building construction – Through the competency framework we have now introduced……………….. PHASE 1 - all operational personnel from FF to GM who are in development have to progress via the Advancement Programme before they are deemed competent. This programme will include IFE modules and assessments, Technical knowledge which includes building construction Introduction theoretical assessments of risk critical skills since removal of statutory exams (IFE) Fire Behaviour Training Challenging Training environment- Ability to search for and extinguish a fire, SFRS are working toward a solution to provide a realistic training environment ( 2 x storey BA Villa complex) ( £500k) K&U + Practical application – fire behaviour – water damage and using water in volume WE MUST TRAIN OUR FIREFIGHTERS TO DEAL WITH REALISTIC SCENARIOS ( BA COMBINATION DRILLS IN FIRE, HEAT AND SMOKE) WE MUST ALSO TRAIN AND PREPARE OUR CREWS FOR FAILURE! – EG, What do they do if it goes wrong??

Next Steps Internal; SFRS to immediately implement the lessons learnt from this Incident Safety Event Case Study. Every Firefighter within SFRS to receive this presentation External: To be shared nationally via the Collaborative Partnership (TOG) INTERNAL – New thermal scanning TICs now issued and every fire fighter in SFRS has received this presentation, delivered by their Stn Manager and are aware of the lessons learnt relating to comms & active questioning of witnesses. EXTERNAL - This presentation and the Template will be available and shared with all FRSs via Collaborative Partnership, (Tactical Operational Guidance)

Sharing the Lessons Nationally Example: - Standard National Template for sharing Case Studies

Any Questions ? “The only real mistake is the one from which we learn nothing”