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Blaina: A perpetual legacy |
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In the second in an on-going series looking back on incidents that fundamentally changed the Fire and Rescue Service, Tony Prosser examines the implications of the catastrophic Blaina fire in 1996
ON THE FIRST OF FEBRUARY 1996, a fire occurred in the South Wales valley town of Blaina. It was a simple house fire, not a complicated incident – the type of domestic fire that many firefighters would regard as a ‘bread and butter’ job. However, circumstances conspired to turn a run of the mill fire into one that had massive reverberations across the British Fire and Rescue Service. Stable door lessons were learned and as a result firefighters are safer due to improved training and awareness of the phenomenon known as ‘backdraft’. At 0603, Gwent Fire Brigade fire control received a call to 14 Zephaniah Way in the small Welsh ex-mining town. The retained station was less than half a mile from the two storey, two bedroom terraced house. Initial callers stated there were no persons trapped in the house and a standard attendance of one Water Ladder was dispatched with six firefighters. A subsequent caller stated that a child was upstairs in the building and fire control mobilised the next nearest appliance from Abertillery, a day-crewed station three miles away. As the first crew arrived at 0609, it received the ‘persons reported’ message and a crew was immediately committed to search and rescue in the first floor taking with them a hose reel jet. Within two minutes they had rescued a child.
Severe Damage
Members of the public shouted that further children were still trapped. Smoke was, in the words of a surviving crew member, “hammering” out of the house but this was the same as the conditions that were seen on arrival. The firefighters re-entered the house at 0615. Within seconds both floors burst into flames. Both firefighters were trapped and died within the house. There were no other children in the building. The damage was so severe that the cause of the fire was not able to be determined. What was difficult to comprehend was that a double fatality had occurred in such a straight forward incident. The investigation into the cause and development of the fire involved the Health and Safety Executive, the Fire Brigades Union and forensic scientific specialists as well as the brigade itself. The overt reasons for the tragedy were relatively straightforward. The initial caller was not aware that there were people trapped in the building. If that had been the case then a different attendance would have been mobilised. Following the first rescue, firefighters were told erroneously of the second casualty, necessitating their re-entry. As they entered, the smoke produced remained largely unburnt until the fire which started in the kitchen broke through the ceiling into the first floor rear bedroom. This resulted in a sudden deflagration which moved from first to ground floor – the phenomenon known as a backdraft. A sliding glazed inner door on the porch jammed closed onto the hose reel taken in by the firefighters which prevented their retreat from the house. There were to be several areas which were looked at in order to understand what had happened and to prevent a reoccurrence. Training of both firefighters and officers was a key factor, as was the whole rationale for the mobilisation of resources. As would be expected the role of breathing apparatus was the subject of scrutiny, including the issue of emergency teams.
Flashover and Backdraft
The Health and Safety Executive served enforcement notices upon Gwent Fire Brigade related to training for operational risks. Among other things it stated that: ‘The training provided did not adequately equip firefighters to recognise and deal with the situation (ie the backdraught) encountered at Blaina’. The recording and monitoring of the training of ‘watch-based training was not sufficiently rigorous to spot areas which had not been covered adequately’. Furthermore, the materials that officers used to support such training as was, was ‘not sufficient to ensure quality training (eg comprehensive bibliographies, lecture packs, overhead slides)’. Finally, the report pithily concluded that: ‘Few firefighters in Gwent had received useful hot fire training’. Ironically, research that had been going on for nearly three years into compartment firefighting and particularly into the phenomena of flashover and backdraft, had just been completed and the preliminary practical outcomes of this research were published. The researchers from the Home Office Fire Experimental Unit concluded that although the phenomena were well known by scientists, the practicalities were not understood by firefighters. The distinction between the phenomena of flashovers and backdraughts had, until this period been blurred and the subject of debate in the Service for a number of years despite relatively clear definitions being available in the Manuals of Firemanship.
The tactics for dealing with compartment fires had been the subject of much work in Sweden for a number of years in the 1980s. The transference of valuable firefighting techniques from one country to another was very poor, as is still the case today. While Swedish firefighters trained to control fires in unventilated compartments, training in Britain was limited to reading several paragraphs about them in the Manuals of Firemanship. One of the reasons why the HSE could be so critical of training of firefighters is that they had produced a Health and Safety Guidance Note Occasional Paper No 8 Training for Hazardous Occupations (known colloquially as the “NIG” – National Industries Group – Report) in the early 1980s. The report emphasised the need for exposing firefighters to risks similar to those that they would face on the incident ground, albeit in a controlled environment. In many aspects of operational skills this was applied, but in the arena of compartment firefighting this was not rigorously followed, due possibly to the difficulty of reproducing the effects in safe conditions. Following Blaina, there was sufficient will to develop such equipment and systems to enable this training to be carried out.
No Guidelines
The difficulties facing firefighters and officers at such incidents were recognised as being not only of an operational but also of a moral nature. In what can only be described as ‘a nightmare scenario’, such as Blaina, firefighters are under enormous pressure by onlookers and family to undertake action, whether or not they have the equipment and skills to do so. Time and again, newspaper reports of almost reckless behaviour to rescue others indicate the willingness of staff to exceed the margins of safety to help the public. Recognition primed-decision making begins when someone is told of the incident they are being sent to. This sets off triggers and begins the process of tactical decision-making prior to arrival. If, on arrival, the nature of the incident changes (going from a ‘normal’ fire to ‘persons reported’), the incident commander is caught on the back foot and having to recover the initiative at the incident from a new start line. At that time, in many services there were no guidelines on assessing risks and benefits. This dynamic risk assessment process was captured, documented and issued by the Home Office Health and Safety Section in 1999, with encapsulated cards of the actual DRA flow diagram being issued to all firefighters in the UK. The DRA might not have been the whole answer but at last it introduced a formal and systematic approach for controlling the exposure of firefighters to excess risk.
A more subtle form of risk on the fireground is the ‘tunnel vision’ that command officers develop when attending serious incidents. Especially in the USA, this phenomenon has been responsible for many serious and sometimes fatal incidents where command officers have been drawn into micromanaging the incident instead of taking a more circumspect view which includes assessing the potential hazards and risks crews are facing. Although not necessarily the case in this incident, it was recognised that the officer in charge had not received the proper training (in terms of recognising the signs of backdraught and flashover) that was necessary to manage the risk to firefighters. Breathing apparatus protocols and procedures have also changed since 1996. Technical bulletin 1/89 (TB 1/89 – the national guidance for the use of breathing apparatus), had been adopted by Gwent Fire Brigade but were not put into place at Zephaniah Way due to the immediacy of the rescue task facing the crew. Stage 1 BA control was not set up as other crew members were working at other safety-critical tasks. Following the flashover two firefighters spontaneously put on BA sets and entered the building in order to attempt the rescue of their colleagues. The revision of the breathing apparatus procedures that were issued in Home Office Technical Bulletin 1/97 (TB 1/97) included the creation of a ‘rapid deployment’ procedure to take into account circumstances where urgent rescues needed to be performed (albeit in the absence of sufficient crew to set up full control procedures). Similarly, TB 1/97 put in place a requirement to set up an emergency team as soon as possible to protect initial BA crews.
Final Challenge
The final major strand of change that was promoted by the events at Blaina was to finally put to rest one of the debating points of the previous decade – the ‘C’ risk controversy. Fire service circular 4/1985 recommended that for a ‘C’ risk area – typically post war housing including terraced houses of the type in Zephaniah Way – the pre-determined attendance was a one pump attendance, taking approximately 8-10 minutes to attend a fire. In a deft piece of sidestepping the issue, the committee did suggest that ‘fire authorities should review attendance policies to determine whether and to what extent, parts of the ‘C’ risk should attract an enhanced attendance of two appliances, the second arriving as soon as realistically possible after the first’. Thus a set of national recommendations, accepted by the home secretary of the day, became fudged (in the case of ‘C’ risk) to a permissory clause, which allowed factors other than operational necessity to become a key influencing factor in the level of response. Several fire and rescue services, including Gwent, chose to adopt a one pump attendance for domestic fires. Thus at Blaina, a single pump was dispatched for a severe house fire but the second pump only dispatched upon the persons reported message being received. The deaths at Blaina brought into sharp relief the ‘C’ risk debate, a subject many fire and rescue services were deeply unhappy about. Many services had already adopted a standard that was informally called the ‘urban C’ risk which recognised the risks associated with property fires in residential properties and sent a minimum of two pumps to all domestic fire calls. The subsequent work carried out by the Fire and Emergency Cover (Pathfinder) Review highlighted the need for a minimum of nine firefighters to carry out operations safely at a scenario such as that one described above. There is a wide acceptance of this approach, supported by a number of methodologies including the critical attendance standard favoured by the Fire Brigades Union. There is a well argued case by the FBU that if the second appliance, from Abertillery, had been mobilised simultaneously, BA teams would have been in position to assist firefighters immediately following the explosion and possibly have been in place to prevent the backdraught in the first place. Twelve years provides a sufficient interval for sombre but objective opportunity for reflection on the tragedy. Have the outcomes of the fire at Zephaniah Way improved firefighter safety?
Without doubt there have been many positive aspects that have either been the direct result of the fire or that the fire has been used to support existing arguments for improving operational fireground behaviour. Breathing apparatus procedures, models of emergency fire cover have evolved and individuals’ knowledge of fires and firefighting particularly in compartments has been systematically improved. Whether the incident lessons can be equally applied to other building fires is more debatable. Certainly there are generic lessons that can be applied to many aspects of firefighting including the DRA and general BA procedures. Compartment firefighting techniques have not been widely used for large open spaces where conditions for backdraughts are unlikely (although not impossible) to occur. Undoubtedly, there will now be an impetus to assess the potential for adverse fire phenomena occurrences in large compartments. Since 1996, there has been much investment in training for the conditions that occurred in Blaina. Firefighter safety has improved and there is a much better understanding of the relationship between crew safety and operational practices. Was Blaina a ‘one off’? The phenomena of backdraught has been observed enough times to know that it was not. Whether the coincidental introduction of air at the time firefighters entered the combustible smoke area will ever be reproduced in a small compartment is more difficult to assess. All that can be said with certainty is that since Blaina, fewer firefighters have been caught in such circumstances with such deadly results. |
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