FireNet Community
FIRE SERVICE AND GENERAL FIRE SAFETY TOPICS => Operational => Topic started by: BB on March 01, 2010, 09:32:48 AM
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Following the warehouse fire at Atherstone in Warwickshire where the 4 fire-fighters tragically lost their lives I have seen on the news that the police have arrested a number of suspects. Rumour has it that they are operational fire service personnel.
Has anybody any further information as the police, news and press have not released any statements.
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BBC site describes them as "fire service staff". FBU site as "three managers" (and FBU members) "involved in the incident command process".
It would presumably be wrong to comment on their potenial identities further while the police investigation is ongoing?
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Check out http://www.kingfell.com/~forum/index.php?topic=4676.0
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Has anybody got any info that they can pm me, please?
Our senior officers are wondering whether this will impact on Command Decison making
davo
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Check out latest info http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-18039494
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I have also come across this website -
http://www.supportwarwickshirefirefighters.co.uk/default.html (http://www.supportwarwickshirefirefighters.co.uk/default.html)
The trial diary make interesting reading.
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A fire service officer has been found not guilty of the manslaughter of four colleagues who were killed in a blaze a t a warehouse in Warwickshire.
http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-18055615 (http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-18055615)
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Fire officers cleared over Atherstone warehouse deaths
http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-18251348 (http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-18251348)
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I have no expertise whatsoever in operational fire-fighting tactics, or the management thereof, (and when I read of cases like this and that of the mine shaft incident in Strathclyde, I am glad enough about that).
However, I am interested in expert witness evidence, particularly after the Cadburys v ADT case, in which the judge said he could not rely on the evidence of the key expert witnesses and then went on to name and criticise each one individually.
In this case, both the prosecution and defence called expert witnesses, whose duty was to assist the Court and could not be advocates for either side's position. I am sure that they would have fulfilled their obligations in that respect.
Nevertheless, I have been unable to find much about the thrust of the evidence of each expert witness, other than snippets in the BBC reports.
Could anyone with no axe to grind give a simple, objective and uncontentious overview of the position of each of the experts, as presented to the Court (while obviously not commenting on the outcome of the case). This is purely academic interest, and it will no doubt be discussed at many a conference, but I would have liked to understand more than I currently do.
Kurnal, is it alright for someone with the requistte knowledge to do this here?
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As I understand it the case revolves around the Dynamic Risk Assessment (DRA) that has to be carried out by operational crews and specifically the officers placed in positions of authority at the incident. The Incident Commander, Sector Commander and Safety Officers at an incident have a duty to ensure the heath safety and welfare of the crews and balance that against a risk benefit analysis. This is roughly based on the mantra to save saveable lives they will place crews at risk, to save property they may place crews at risk, but crews should not be put at risk for lives or property already lost.
In this case there appears to have been a difference of opinion between experts as to the understanding of risk as balanced against operational tactics by crews. I believe there are other issues around the understanding of: building construction, fire development, tactical ventilation, along with issues regarding information gathering prior to the incident, communication of intelligence within the FRS, training and the recording of training. From what I can see not all of this has come to light in Court.
Obviously the average fire fighter and fire supervisory manager, or even senior fire manager, is not going to have as much academic understanding of fire development as a scientist. They need to have sufficient knowledge and understanding appropriate to their role. They then use information to hand at the time, both gathered and observed at the time and having been pre gathered and disseminated prior to the incident, to make tactical and operational decisions based on recognition primed decision (RPD) making. This means the tactics used are normally the “best fit” to deal with a developing situation and are not always ideal or even correct. The operational tactics should be reviewed and changed as appropriate based on developing information.
The verdicts show the officers charged did this within their required skill base.
Commanding fire crews (or any emergency or military service) requires command staff with the ability to make quick value based judgment. This in itself is a skill. One which many academics do not possess.
Is there anyone on this forum who has followed the case closely that can shed more light on this?
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Colin I dont know if you have seen the daily diary on the support warwickshirefirefighters website and although it represents an outstanding account it may not have the clinical integrity to satisfy your level of interest.
http://www.supportwarwickshirefirefighters.co.uk/Trial-Diary.html
Congratulations to SamFIRT for an outstanding succinct analysis.
There have been parallel H&S proceedings against the County Council and I expect that until the full outcome and details of both cases are amalgamated we shall not see the full picture.
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I'm not sure that one of the expert witnesses was that expert
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Expert. An ex is a has been. A spurt is a drip under pressure.
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Samuel, thanks for the overview, which is helpful.
Big Al, I was totally fascinated by the diary, and it confirms that the fundamentals in the case are surely a difference of opinion between experts.
Samuel, there is a famous case involving the death of a baby at the stage of a tricky delivery. A junior houseman did something that was alleged to result in the baby's death. One party produced an eminent professor of obstetrics, who said (with armchair hindsight) goodness me what a silly thing to do, no wonder the baby died, but the success of the defence arose from a few "average" housemen that demonstrated that they were not professors of obstetrics and the average houseman on top of the clapham omnibus would have done the same thing. Is that an analogy of the point you make?
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Colin
Yes that is a reasonable analogy.
I believe that in order to prove the fire officers were culpable the prosecution would have to prove they were not competent fire offers as appropriate to their position in the fire service, (what used to be called rank) and as appropriate to the role they performed at the incident.
You are also correct in that it is very easy to slowly armchair analyse in great detail the actions of staff at a fast moving dynamic situation and decide actions could have been better. That is the fundamental difference between a Dynamic Risk Assessment (DRA) and an Analytical Risk Assessment (ARA). Doing this it is easy to assume that all the information available retrospectively to the armchair analyst, would have been available to all the key players at the time in the same sequence. Fire-ground communications are never that good!
For training staff; carrying out an ARA and critical assessment of the DRA actually undertaken at the time of the incident, whilst undertaking a case study or debrief of a previous incident, is an excellent way of training managerial fire staff, and can improve future DRAs of both the staff involved and others. It does this by building on the memories, knowledge and understanding of the staff involved in both the original incident and those involved in the training that were not at the incident. However, it must be carried out as critique and not criticism in the spirit of the “no blame culture”. Otherwise both the staff concerned and others will not only, not learn from the experience, they will unlearn the confidence gained previously and diminish their ability to apply the RPD skill set.
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I have spent the last six weeks attending Stafford Court every day to find out why my husband Ian died in the Atherstone on Stour fire on 2 November 2007 with the expectation that the truth would be told by his colleagues who were there that night, both the Incident Commanders and all others who entered that fire compartment. A fire compartment in which a pallet fire had been reported at 17.40 and was still being treated as a pallet fire at 18.56 when my husband entered the compartment. What I never envisaged was three Incident Commanders with a total lack of courage to take the witness stand and give their version of events and defend their actions on the night. What I also witnessed was successive Warwickshire firefighters suffering selective memory loss as to what instructions they were given by the Incident Commanders before their entry into the fire compartment. In fact it was completely evident to me that all Warwickshire firefighters had been coached on how to conveniently forget that night and this coaching must have only been provided by either Warwickshire Fire and Rescue Service or the FBU. These men watched my husband dying in front of them - how can they possibly forget that night? Why would they not want the truth to be told and why would the FBU also not want the truth to be told. Ask yourselves this, why only weeks after the incident did FBU officials attending witness interviews instruct firefighters not to answer questions? No one had been arrested and no one had been charged with an offence and yet the FBU sought to cover up what actually happened that night. All I wanted was to get to the truth in order that lessons could be learned to save firefighter lives in the future and avoid other families going through the nightmare me and my daughter have experienced. The FBU and Warwickshire firefighters have let me and my daughter down and more importantly have let my husband down.
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Julie
God bless you and your daughter and rest assured the memory of your husband and his ultimate sacrifice will sit deep in the hearts of all of us for ever. Thank you for joining our forum and sharing your thoughts and feelings with us. None of us can begin to understand how the tragedy that unfolded at Atherstone has impacted on the families affected. I cannot defend the fire service and its closing of ranks - I have seen it happen before following a tragic event..
If you see in these forums apparent support and sympathy for those in the dock please rest assured it is nothing compared to our sorrow and loss at those who died. As serving or past fire service officers I am certain we all share the one over riding and driving aim- to bring all of your team safely back home again. Our sympathy extends to those who failed to do this and there, there but for the grace of God go all of us. Almost any serving fire officer could find themselves in this position every day. I know having been close to it myself on one occasion. We were lucky thank God....
Every system and every procedure will always be subject to Human error. The biggest enemy of the system is when the red mist descends- mis perception and mis information lead to a mis interpretation by the key operational manager and the pressure to be seen to be doing something leads to wrong and potentially dangerous paths being taken. Should such operational decisions and authority rest on the shoulders of one individual? For a rapid and decisive response it is important that it does. But it leaves us all very vulnerable to the red mist. When hindsight proves that wrong decisions were made should it be the individual or the system on trial?
In this prosecution it was as though the tragedy was entirely the fault of the individual officers on their own. They were not working in isolation, they were operating a management system. The entire prosecution case appeared to be based on the opinion of one expert witness whose views as expressed appeared to be out of kilter with custom and practice. In my opinion if a case was to be brought it should have been considered against the system and structure as well as the individuals. The case against the system and structure would be for a failure to ensure an effective review, overview and control system exists within the dynamic risk assessment process to include a review of the task and objectives in addition to the tactics.
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Colin
agree with you apart from the clapham omnibus bit, thats from another case and may confuse.
The point is, with all their experience and training, site obs etc, was the decision reasonable? It would seem so.
In regard to blame, we used to tell students that management would back any reasonable action but not anything stupid
davo
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Davo, I thought samuel agreed with that. The average man is the man on top of the clapham omnibus. Why is the average medic, consultant or fire officer simply the medic consultant or fire officer on the same bus. That tends to have been case law of a sort. I have always been advised by top legal professionals that, as a professional, I can rely on that unless custom and practice in the whole profession is bad.
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Julie R Please accept my condolences. I too would wish truth to be displayed. Hopefully this discussion may assist.
Kurnal When hindsight proves that wrong decisions were made should it be the individual or the system on trial?
I agree.... H&S legislation should expose corporate as well as personal failure.
Colin / Davo......Whilst I accept the analogy and the point of the person on the top of the Clapham omnibus being *an average person*; in this case we are discussing staff holding positions of authority, for which a degree of technical competency has to be displayed.
A professional person must be adjudged against others, holding similar positions, in similar organisations. I feel the shorthand of the man on the Clapham omnibus being the average person holds true if we are choosing the definition average to be of the the skills knowledge and understanding of the average watch manager / station manager etc.
So I think you both have a point.
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JulieR and all the other people involved, please accept my heart felt condolences.
It doesn’t surprise me these expert witnesses differed in their opinions because a group of similar qualified individuals given a fire scenario will all come up with different solutions, despite the fancy words it’s not a scientific discipline, it’s the experience you gets from doing it, either on the training ground or the fire ground and learning from your mistakes. As was said before a course at Moreton “most fire service subjects are about 20% knowledge and 80% common sense” and there is a lot of truth there.
As for the truth, that went out the window when these three individuals were charged and went to court. The court system is adversarial and is about two sides, one side trying to prosecute you, the other attempting to prevent it, at any cost within the law. I suspect the accused were advised not to take the stand by their barristers in case they said anything to jeopardise their case and witnesses tend to have selected memories. I don’t think we will ever get to know the full truth.
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Samuel, that was my very point. Bear in mind I do not claim to know a jot about operational firefighting, but it is the principles of this case that interest me. The point I was making about the bus was that, if you follow case law from other professions, all that is expected from a watch manager is what the average watch manager would do in the same circumstances at the time in question, not what the highest skilled operational senior officers might, with hindsight, believe should have been done-that was the anaolgy pf the medical case.
Thomas, you are right about adversarial positions, other than in respect of expert witnesses, whoe role is purely to assist the course and not those instructing them. Indeed, the law in England (though not to the same degree in Scotland) requires an expert witness to be impartial and to state in their report that they understand that their duty is solely to the court and that they have complied with that duty, along with a statement of truth that makes them open to perjury charges if they have not stated what they genuinely believe to be true.
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I think one of the issues here is that of the measure of competency appropriate to rank, (or is it role now?) From what I can remember competency in command and control was never an issue when it came to promotion and there was no additional training provided to ensure that with promotion comes greater responsibility and accountability especially on the fire ground.
There did seem to be a greater need to demonstrate an ability to time manage and prioritise effectively as, I suppose, the greater part of the job was the planning and management of projects and, of course, the old box ticker - budget management. The bigger the budget you managed the better.
I would say that I do recall some excellent operational officers who were let down by a weakness in the office and they fell by the wayside as the new Fire & Rescue Service wanted a hierarchy of managers rather than commanders.
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My next comments are purely hypothetical and in no way are intended to reflect directly on this case and are in no way intended to offend.
A lot of the contributors to this forum are (or seem to be) of advanced years. Many are retired or long serving fire service officers. Many hanker for a mythological “good old days “whilst they “swing the lantern”.
However, the British fire service has moved on. There is a different culture. There is a different command and control system. There is better PPE and fire fighting equipment. There is a different selection promotion and appointment system.
How much technical knowledge has to be demonstrated before a person is appointed? How much experience has to be gained? What technical standards have to be demonstrated? How well does an organisation disseminate acquired intelligence? How widespread is the buy-in for new operational techniques? How good is the training in the organisation? Especially command training; what with the reduction in operational experience, with less fire calls and differing shift systems. What is the methodology of recording that training and the levels of competency of those trained?
What I would like to know, following any enquiry into any FRS, is; what, if anything, any of these factors contributed to the outcome?
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You might have answered some of your points already in your signature Sam.
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I think there's still some stuff to be done in terms of an outstanding prosecution of the FRS itself (HSE) and then a Coroners inquest. Hopefully some of these questions will be answered then.