Just over 30 years ago, a fire occurred in the East End of London that led to seismic changes in the way the UK Fire and Rescue Service trains, learns and is even managed. The fire, which led to the death of two firefighters brought about by a series of failures in operational procedures, opened a can of worms which, even today is having an impact on the service. It led to the serving of the first improvement notice on a fire and rescue service by the Health and Safety Executive (HSE) and the consequences of the notices are still here.

The Building

The fire itself, as is often the case, was nothing that would normally be deemed as “exceptional” or “unprecedented”. The premises was located on the east side of Gillender Street (Nos 24-26), Bromley by Bow in the London Borough of Tower Hamlets. The building was constructed of brick walls, concrete and steel floors with a concrete roof covered by asphalt. It was seven floors high and had an area of about 5,000 m² in total.

The premises had originally been fitted with sprinklers under Section 20 of the London Building Act but as a result of the introduction of the national Building Acts, the sprinklers were removed in 1986 because the requirement was superseded and made redundant. The building was owned by Hays Business Services Ltd and rented by several other companies for storage.

The Fire

The fire started on a second-floor mezzanine compartment that scored documents. The fire was detected by the automatic fire alarm system at around 1423 on July 10, 1991 and the alarm monitoring company, ADT, was notified of the actuation at that time. While the ADT operator was in the process of calling the fire brigade, at 1425, the premises rang ADT and cancelled the original call. This was done to allow the security staff to investigate the circumstances.

On their arrival at the compartment, security staff confirmed indicators of a fire were present. They initiated a full evacuation of the premises and made a further call to ADT confirming that this was a fire and requested that the fire service be called.

The First Attendance

The first call to the fire service was received at 1430 and mobilised three pumping appliances (as the premises was determined to be in an “A” risk area) and a turntable ladder. The first pump from Poplar arrived at 1436 and the incident commander (sub officer) located the alarm panel and found that fire was showing on the second, second-floor mezzanine and third floors.

Crews started setting into the dry rising main ready to provide water. Having examined the alarm panel and available plans, the incident commander (now a station officer), decided to investigate the second floor mezzanine area. Firefighters then went with the security guard who suspected the fire was in electrical equipment. They carried a BromoChlorodiFluoroMethane (BCF) extinguisher with them. On the second floor mezzanine entry they found a wispy smoke and the station officer instructed a crew to rig in BA and then set up a BA entry control point on the second floor staircase.

The BA team of four made their way into the building, taking with them a BCF extinguisher, water extinguishers and a pair of bolt croppers. They were instructed to investigate and report back. The team located the fire and requested a hose line to be deployed along with a jet. They deployed a 45 mm hoseline consisting of four lengths and terminating in an adapter to which a length of hose reel tubing had been connected by an improvised adaptor and terminated in a hose reel jet (HRJ).

The hose was charged and crews entered the fire compartment, which, by this time, was giving off an intense heat and smoke visibility only being around two metres. This team withdrew because of the heat and stated that a main jet would be required. A relief team replaced the initial team but found the HRJ ineffective and they were unable to attack the fire. Crews withdrew from the fire compartment but the fire resisting doors were left partially open because the hose prevented closure.

Complications

Outside the building, a “make pumps six” message was sent at 1509 (33 minutes following first attendance) by the station officer. Among the reinforcing appliances were pumps from Silvertown and Stratford fire stations. Around 1519, a divisional officer took command and instructed a second jet be taken to the mezzanine floor. He sent a “make pumps ten” message at 1535. He also instructed another jet to be made ready for an attack from the rear of the building into the second floor mezzanine.

A 70 mm hoseline was taken to the second floor mezzanine and 20 m down a corridor when the crew (team of four BA) encountered significant heat. They inspected the floor above and below for signs of fire spread but found none. They returned to the 70 mm hoseline and made their way into the compartment but found the line too short and withdrew from the building. The 70 mm hoseline would remain uncharged throughout the incident. Outside they explained the issue to the newly arrived (at 1535) ACO who they assumed in error was now in charge (he formally took command at around 1600).

At around this time the incident commander (divisional officer) initiated a BA main guideline to take crews quickly to the scene of operations on the second floor mezzanine. A BA team of four, complete with communications, was instructed to lay the guideline. This “mixed” team , “Silvertown 1” consisted of two firefighters from Silvertown, one (David Stokoe) with 18 months’ experience and one (Terry Hunt) with 12 years’ experience, a station officer and a probationary firefighter (with three weeks’ experience) from Stratford.

The team leader (SO) was connected to the guideline and the others attached by personal line to the person in front. The guideline was laid but was required to be extended with a second guideline to reach the fire compartment. It was subsequently found that the guideline tallies were not properly connected to the line and the method of joining the two guidelines was incorrect.

By this stage, communications was proving to be problematic and the station officer started using his own radio to ensure messages could be transmitted and received. By the time the team had reached the end of the hoseline (uncharged) and the hose reel, the conditions were reported to be difficult. Having taken a BA cylinder air check just before withdrawing, the SO took the probationary firefighter to view for himself the fire conditions that would help him prepare for future incidents. After a few steps into the compartment, they found conditions untenable and withdrew.

At about 1600, a branch line was ordered to be laid from the main guideline on a right hand search to look for fire spread. Having made their way to the second floor mezzanine through what were increasingly difficult conditions, the BA team (“Silvertown 2”) came to what they believed to be the end of the guideline (the guideline bag was on the floor and smoke density was heavy and thick. They laid the branch line as instructed to the right to permit the search for fire spread but incorrectly attached it, which may have led to subsequent confusion.

Due to the heat and intense smoke, they became disorientated and laid the line back along the same corridor down which they had laid the first portion of the branch line, in effect creating a condition where the directional tabs on the lines indicated both the way in and way out of the building were only a few centimetres from each other. In other words, the preconditions for confusion were in place.

As Silvertown 1 began to withdraw, they came to the point where the initial guideline (A), the guideline extending the initial line and the branch guideline joined together. With air running out and heat and smoke increasing, there was understandable chaos, distress and confusion: the team, believing they were heading out, were confused by the positioning of the tabs indicating they were heading back into the fire compartment.

Eventually, a “tangle of guidelines” was found and after a disagreement the SO, now with his low pressure warning whistle actuating, and the probationer, followed one line which eventually led to the second floor mezzanine staircase. By the time they reached the staircase, the SO’s cylinder was nearly empty (the whistle was silent). In the confusion, this part of the team passed another BA team (Silvertown 2) but were too physiologically exhausted to communicate effectively their distress. As they entered the staircase the station officer collapsed onto two firefighters causing a high-pressure hose leak in one BA set with his own cylinder now exhausted. He was carried out by two firefighters and his face mask removed to help his laboured breathing, all with the probationer still attached by his personal line.

The “part” team left the building at around 1630 and following treatment by ambulance staff, the SO was taken to hospital at 1743. Debriefing of the team was difficult due to the distress and exhaustion suffered but the probationary firefighter told others that the other two firefighters in the team were going in the wrong direction.

At 1644, a further team of four was committed to the building and made their way along the main guideline to rescue the missing firefighters. They silenced the fire alarm bell to listen to what they believed to be an automatic distress signal unit (ADSU) and locating its proximity made their way through the double doors following the hose.

They found both firefighters immediately, semi-reclined, both ADSUs operating. Vital signs were checked but there was no pulse and their cylinders were empty. The team struggled to get both firefighters to the nearest doorway and were running out of air themselves. They met a team from Leytonstone, who despite this being their third deployment into the building, began the firefighters’ evacuation, assisted by firefighting teams from Bethnal Green and Lee Green and Stoke Newington pumps.

The first casualty (Ff Hunt) was rescued at around 1725 and after attempts at resuscitation at the incident, was removed to the London Hospital at 1739 but was pronounced deceased on arrival. Ff Stokoe was rescued at around 1740 and taken to hospital where, once again, death was pronounced at 1802. Seven other firefighters were injured at the fire, which eventually took 20 pumps to control with the fire surrounded message being sent at 1951 and the “stop” at 2045. The incident was closed at 2051 Friday July 12, 1991.

Investigation

London Fire Brigade began a detailed internal inquiry immediately which identified a range of issues, some seemingly straightforward, some less so. Their findings included the delay in calling the fire service caused by the investigation by security staff to ascertain the validity of the alarm, ironically a protocol now positively endorsed by many UKFRSs in order to reduce the incidence of mobilisations to AFAs.

Preplanning, risk awareness and local knowledge were also found to be deficient (has anything changed in the intervening years?) and practical skills – firecraft – found wanting particularly with respect to breathing apparatus operations and the application and use of improvised equipment (the hose reel adaptor for the end of hose was not a piece of service equipment). Operational control and tactics of the incident was criticised with a slow initial “make up” (33 minutes from arrival of first pump), confusion at time who was in charge, perceived multiple commands and problems with communications, especially radios (again!) as well as an inappropriately light initial attack and hose ready for use that remained uncharged throughout the fire.

Breathing apparatus procedures and their application were heavily criticised and found to have significant failings and omissions. Mixed crews were seen as bad practice, although today, with low levels of crewing in many FRSs, “mixed crewing” is far more prevalent than 30 years ago. Officers were criticised for using probationary firefighters at the incident with one team of six being led by a probationer, BA board clocks were not synchronised, the initial BAECP was located on the second floor staircase but subsequently relocated as a result of the fire growth and there was no dedicated emergency crew available for much of the incident.

Fundamentally, despite uncertainty of the number of missing firefighters, many BA tallies were not collected on withdrawal from the building and perhaps most pertinently at this incident, the correct use of guidelines, branch lines and personal lines was not demonstrated effectively at the incident and remains a critical element in the chain of events. As experienced many times before and since, there was a failure to understand and recognise the impact heat stress can have on BA wearers and the consequences of the distress that can occur. This could have been identified by effective debriefing and welfare assessments of exiting BA team members as to the conditions occurring in the building at the time.

The Wider Investigation

Unsurprisingly, the tragedy sent shockwaves across the service and the Health and Safety Executive (HSE) became involved in the investigation. Two improvement notices were served on London Fire Brigade concluding the ‘service was not providing adequate training and development for its people’. These improvement notices were to cause a sea change across a whole range of aspects across the service, perhaps unfairly on the part of some FRSs.

The notices led to two main strands of the change process. The first was the introduction of training where competence was the underpinning principle. The second aspect of the notices were to lead to the introduction of the Integrated Personnel Development System (IPDS). A Training Strategy Group (TSG) developed ideas and concepts that were radical and ultimately led to the abolition of both statutory examinations and a promotion system underpinned by legislation.

While many of the ideas and developments had much merit, it appeared that the baby had indeed been thrown out with the bathwater and failed in some of the key aims of IPDS. This included the diversification of the service and its opening up to multi-tier entry processes, family-friendly work patterns and a less rigid progression and development structure. IPDS, promoted/forced through by the Labour government in the bitter aftermath of the 2002-2004 firefighters’ national dispute, destabilised the UKFRS for over a decade until it was allowed to “fade away” like an old soldier but not as fondly remembered.

Differential application of development and promotion processes by 52 or so FRSs helped to create a parochial system in each service and the loss of a standardised approach to management at all levels ultimately led to the neutering of the “Centre of Excellence” – the Fire Service College, despite it being the temple of the IPDS believers. Evidence of IPDS as an entity is scant today, a memory best consigned to the repressed part of the collective brain as services try to standardise all aspects of service provision and delivery through national bodies and use Institution of Fire Engineer exams as a substitute for statutory exams.

And yet it could have all been so different. The HSE investigation looked at the processes that LFB had in place for training and the issues both they (and LFB to their credit) identified. Cultural aspects that underpinned some aspects of the failure were not necessarily investigated (at least publicly) and it is still a common assumption to equate activity levels of a fire station with the level of competence. A station attending 3,000 calls a year can often be assumed (by those at that station) to have more experience, be more proficient etc than a station attending 500. As a consequence, the requirement for routine and formal training may be perceived to be less important. But if the 3,000 calls are actually 500 “real” incidents and 2,500 are AFAs (as is still the case in many urban and city centre stations), is that perception correct? It has been speculated that the “busy = competent” culture was more prevalent in the last century and this may have led to operational failures at a systematic level across the UK caused by a failure of rigour in assessing training regimes for high activity stations.

But the question is, did it really change the service? Do we now have better trained, more knowledgeable firefighters and better organisation on the incident ground? Superficially, the answer is “yes” and the evidence appears to support this answer as no firefighter has died in a fire incident for over eight years. But, if the Silvertown 1 had stuck together, if the two firefighters had hooked onto the other (correct) guideline and came out safely, would we have known about the range or severity of failings? The odds are that we would not.

As with other fatal incidents involving firefighters – Blaina, Paul’s Hair World, Atherstone on Stour – there seems to be a set of underlying and root causes for the tragedy but it is only fate that allows the holes to line up and end in tragedy. How many fires are being attended in the UK right now where there are multiple critical failures occurring but the final, fatal link in the chain is missing? Firefighters have been trapped in high-rise building lifts having taken the lift to the fire floor, diving out of windows when trapped by fire in domestic properties. How do senior officers and service managers truly “know” what is happening on the ground? Thankfully, there have been no firefighter fatalities in building fires for over eight years. How confident are service leaders (including political leaders) that this is pure luck and not judgement?

Tony.prosser@artemistdl.co.uk