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The Penhallow Hotel fire: accident, arson or incompetence?

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Following last month’s £80,000 fine on the owners of the Penhallow Hotel in Newquay after the fatal fire there in 2007, Alan Cox asks whether we have learned the whole truth about the tragedy. And in response to some of his claims below, Cornwall Fire and Rescue Service set out their version of events.

The fire at the Penhallow Hotel has been described as the worst in a UK hotel for nearly 40 years and tragically resulted in the loss of three lives. But with the standards and levels of enforcement which have been developed following other tragic fires, should it have happened and was it because of an accident, arson or incompetence?

Let me start by saying that I don’t know whether the fire was an accident or arson. Although I have spoken to some of the witnesses and others involved in the case together with attending parts of the inquest, I have not been able to form an opinion one way or another. Although the police and the fire service appear convinced that it was arson, evidence for this has not been produced in public.

It is alleged that the fire was started with a naked flame but there is no evidence to substantiate this and no witnesses to this event. In addition, there was conflicting evidence given at the inquest and even the experts said it could be arson for the simple reason that they had ruled out other possible sources.

To some extent, however, the question as to the cause of the fire is a little academic; had the standard of fire precautions been to an acceptable level, the guests should still have been able to escape safely in most circumstances. I believe the focus on whether or not it was started deliberately may have distracted people from other aspects of the investigation.

Incompetence?
Whether accident or arson, I have certainly concluded that incompetence played an important part in this tragic fire. Firstly, some background information, but please be aware that I did not have any official role in this investigation and the information I have obtained has been from speaking to some of the people involved, from Freedom of Information (FOI) requests, and from attending part of the inquest. In the absence of an official fire investigation report, this information is made available and I hope it will enable us to truly learn from this tragic incident.

It is thought that the hotel was constructed between 1912 and 1917 and was of a traditional construction of the time. A number of alterations were made in subsequent years to give the building the appearance that it had at the time of the fire. In 1990, plans were approved for further alterations including the removal of a staircase and the installation of two wooden fire escapes, which formed the main fire escape routes.

The first fire certificate was issued on the 22 September 1976 and was subsequently amended and re-issued on the 20 November 1991 and again on the 6 March 1995. It is assumed that the 1991 amendment was made following the installation of the two new wooden external fire escapes but the reason for the 1995 amendment is not known. After submitting three FOI requests which were rejected for copies of the 1995 amendment, I finally obtained a copy in May 2011.

Fire service visits
Whilst I have not been able to obtain a list of all of the visits that the fire service made to the hotel, I consider these to be the most important:

17 July 2006 – A visit was made by two fire safety officers to carry out a fire safety audit (prior to the introduction of the RRO). Following the inspection they discussed the audit with the hotel manager who produced a risk assessment, which indicated that the fire alarm required upgrading. The fire service officers indicated that the PAT (portable appliance testing) was out of date, there were no test records for the fire alarm or emergency lighting, the fire doors were not up to standard, the glass bolts on the fire exits required changing, and there were large areas of glazing adjacent to the fire escape that required changing. It was also noted that the rear fire escape was in a poor state of repair and an enforcement notice was issued to rectify this within seven days.

27 July 2006 – A visit was made by the fire service but the repairs had not been completed and so an extension of five days was granted.

2 August 2006 – A further visit was made and the repairs were approved.

18 July 2007 – A visit was made to review the Tactical Information Plan Risk Assessment (TIPRA) for the hotel, which was categorised as a medium risk. But the inspection revealed a void between the original flat roof and the subsequent roof built over it, which could have allowed fire to spread whilst being undetected. This resulted in the TIPRA being updated to a yearly inspection instead of the existing three yearly cycle.

During the visit the hotel manager drew to the attention of the fire service a leaking hydrant outside the hotel. An unsuccessful attempt to stop it leaking was made so they agreed to get it repaired.

In order to clarify these visits I submitted the following FOI requests to Cornwall Fire Service:

  • Was the building of a new roof over the existing hotel roof notified to Building Control or had it been subject to a previous building regulations application?
  • Were cavity barriers recommended to the owners if not already installed?
  • Was automatic fire detection for the void recommended to the owners?
  • It is understood that a ladder could not be pitched to the front of the hotel to rescue a trapped guest because of a low wall and parked cars – why was this not identified in the TIPRA?

All the replies to these questions were: “information not held”.

These were very important visits because they highlight what I feel are significant problems with how the fire service went about their business.

Firstly, I think that when the fire service carry out a fire safety inspection such as the one on the 17 July 2006, the outcome should always be confirmed in writing because expecting an untrained person to understand the gravity of the situation is unreasonable and this needs to done in a formal manner. This is even more important if the person who they are speaking to is not the owner, as was the case with Penhallow Hotel, and I certainly know that this is the practice in some other fire services.

Secondly, when the fire service carry out operational visits they should make sure that access difficulties, water supplies and defects are recorded and notified to the correct department. In my opinion, simply answering “information not held” reflects very poorly on their reputation and efficiency.

Some people will say that it’s easy to be wise after the event but when you consider that these things have been normal practice in many fire services over the past 40 years, you have to wonder if we really are moving forward.

Management actions
I have spoken at length to the hotel manager about the way that fire safety was managed at the hotel. I got the impression that he was poorly equipped and trained to carry out this role and never fully realised the failings in the hotel’s fire safety arrangements.

The risk assessments that I have seen fall very far short of what I feel would be required to meet the statutory requirement and consist of a generic list of hazards, risks and control measures, together with a generic information sheet about the Regulatory Reform (Fire Safety) Order. This information sheet makes the point that “Fire can be a serious problem for hotels. It can result in serious injuries, multiple fatalities and damage to property. However, if all the control measures are maintained the risk should be ’low’.”

The risk assessment carried out by hotel personnel in respect of the fire alarm states: “It has been noted that the fire alarm system will require updating to include the new L2 system for additional detection for all of the hotel.” There are no dates for this work indicated or person responsible for this shown on the form.

The fire
Just as the actions of the fire service and management leading up to the fire raise a number of important questions, so has the operational response to the incident. These are some of the issues that I have identified:

  1. Why did the first fire appliance go to the wrong address? The inquest was told that the Turnout Sheet indicated some confusion between a fire involving farm machinery, and a fire in the bar at the Penhallow Hotel! When I asked why the first crew made their way to “The Crescent” when the hotel is actually positioned in “Island Crescent”, and I requested a copy of the Turnout Sheet, I was informed that it had been shredded. This appeared very strange to me when you think that this was a murder investigation and so I requested a copy of their document retention policy, to which I was informed that this could not be released as it was subject to a confidential commercial agreement.
  2. Why was there confusion about the attendance time of the first appliance? When I asked what time the first appliance had booked in attendance I was informed: “The first appliance in attendance was Newquay (511R), unfortunately they were not booked in on the incident log until later, due to fire control operators taking multiple repeat calls at the same time.” The incident log does show the first message from the fire ground from 511(R) to ‘Make Pumps 4′ at 00:26:45. This has been confirmed to be the attendance time for 511(R).” This is at variance with the information given at the inquest because the crew indicated that they sent the ‘Make Pumps 4′ message when they were at The Crescent because they could see the fire in the distance, so it would appear that the actual attendance time was several minutes later. A local taxi driver told me that Newquay was very busy on that evening and this route would have added several minutes to the attendance time.
  3. The first crews to arrive stated that they found difficulties in pitching a ladder to the front of the hotel to carry out a rescue, due to a low wall and parked cars. Why were these difficulties not foreseen when the fire service carried out familiarisation visits on previous inspections?
  4. Why did the first appliances run out of water? At the inquest the crews indicated that they had run out of water fairly early in the fire and that they had also suffered blockage problems. Some of the witnesses also indicated that the crews did not appear to know the location of fire hydrants, as they were asking hotel staff for the hydrant locations. There was also confusion about how much water the appliance carried, with one member of the crew stating 1800 litres and another stating 2,250 litres. Running out of water and not knowing the location of fire hydrants is considered to be poor firemanship, which could have been overcome with a ’water map’, which could have been checked on the way to the fire.
  5. What really happened to the second appliance from Newquay? Clearly they were expected to attend the station but never turned up, and so this question remains unanswered but points to an unsatisfactory attendance and control system.
  6. Why was an Aerial Ladder Platform (ALP) not available? The official reason was that both these appliances had broken down prior to the fire, but this appears strange when the duty operations officer was only made aware of this fact early on into the fire. Whereas other fire authorities might be able to summon assistance from neighbouring fire services with very little delay, this is not so easy in Cornwall with its relatively isolated location. However, I am informed this is what they were relying on for the provision of an ALP which proved to be of little use, due to the distance and time it took. Even though the fire service says the absence of an ALP made no difference to their response to the fire, I feel that they should have undertaken a risk assessment when the first ALP went out of commission, and that there should have been contingency arrangements in place to either borrow or hire another appliance.

Why did the hotel burn down so quickly? In my opinion there are three main reasons. It appears that the fire started in a store which had been constructed underneath one of the timber fire escapes. Because this store was not constructed from fire resisting materials, the fire very rapidly spread to the wooden fire escape and back into the hotel. It is not known when this store was constructed but I believe it is likely to have been seen by members of the fire service during their inspections. If so, why didn’t they identify the problem and even if they had no statutory powers, they could have reported it to building control to take action.

The question also has to be asked: Why didn’t the owners request building regulation approval? It’s also clear that this rear wooden external fire escape was not adequately protected from a fire starting within the building, so why didn’t the fire service address this when the new fire escapes were installed and they amended the fire certificate? The need to provide adequate fire protection to external fire escapes has been around for nearly 40 years, so this would have been a very serious failing.

One of the other major reasons that the fire spread so quickly was the provision of a light/ventilation well – which doesn’t appear to have been adequately protected from the spread of fire – that linked the upper floors of the hotel and acted as a chimney for the fire. In my opinion the significance of this well should have been recognised many years ago and appropriate fire protection should have been provided to prevent this possibility.

Clearly the first crews that attended the incident had an impossible job to do with the lack of preparedness, appliances, manpower and water. Add to this the defects in the building’s fire protection, and the result was somewhat inevitable and, in my opinion, foreseeable.

Conclusions
There are a number of conclusions that arise from this tragic incident and it is hoped that many of them will now have been actioned. But one important question still remains: Should fire services be responsible for investigating fatal fires where they have been responsible for enforcement? In my opinion, it is now time to move forward to a system where in these circumstances, the investigation is carried out by an independent body.

Alan Cox is a fire safety consultant and campaigner on hotel fire safety standards. He was previously a fire safety officer in the public and private sectors.

Response to Alan Cox’s article from Cornwall Fire and Rescue Service
In respect of the comments and points raised by Mr Alan Cox in his article, The Penhallow Hotel fire: accident, arson or incompetence?, the following is offered to provide clarity, and to address some of the misconceptions and questions that have arisen as a result of the activities that took place both during and after the fire.

Cause of the fire
The fire investigation (the report of which was presented at the Inquest that was held in June 2009 and therefore within the public domain), was undertaken by a team of qualified fire investigation officers from Cornwall Fire and Rescue Service (CFRS), who were assisted by scenes of crime officers from Devon & Cornwall Police and independent fire investigators appointed by the police. We also invited and received support from other FRSs acting as critical friends. In addition, the report was also subject to scrutiny by consultant forensic scientist, Roger Ide, all of whom in turn endorsed our conclusions.

FOI requests and fire certificate
During the course of the investigation Cornwall Council received numerous requests made under the Freedom of Information Act (FOI), that at the time were turned down. Whilst in part the frustration caused by this decision is understandable, the reason not to release the information was in all cases due to concern that if published, it would potentially undermine the investigations that were in progress. The decisions were based on legal advice and subsequently supported by the FOI Commission following applicant appeal.

The reason for the 1991 amendment to the certificate was due to minor alterations that affected the internal layout; it was not for the installation of the external escapes – these were already in place as a requirement of the certification process undertaken in 1976. On 7 September 1992, the hotel submitted a building regulations application to re arrange accommodation to eight bedrooms with en suite facilities on the first floor, and convert the manager’s flat into three bedrooms with en suite. This proposal required an additional exit to the rear of the hotel linking to the existing external fire escape which provided means of escape from the second and third floors. After being initially rejected, the application was passed and works completed. The fire alarm was extended to provide smoke detection in the new bedrooms which were also provided with FD30s fire doors. As the external fire escapes were existing, protective measures were only applied to the new short section of escape, due to the constraints imposed by the statutory bar.

Fire service visit – 17 July 2006
It has been reported that the hotel was subject to a fire safety audit. This was not the case as the RR(FS)O was not in force at the time of inspection. The visit to the hotel that took place on the 17 July 2006 was part of a pre-planned routine re-inspection under the Fire Precautions Act. As the fire authority were planning for the introduction of the RR(FS)O, this pre-planned visit afforded our fire safety officers an opportunity to familiarise themselves and the hotel management with the new audit form and audit process.

As this was an inspection carried out under the Fire Precautions Act, an enforcement notice was not issued; the contraventions found at the time were recorded on a notification of defects form.

Fire risk assessment
The RR(FS)O was in force when the fire occurred; the fire risk assessment obtained during the investigation and subsequently resulted in the company pleading guilty under article 9. The company claimed they relied on an advisor for fire safety matters including the fire risk assessment. This was disputed by the advisor who claimed he was undertaking general health and safety inspections and his services did not extend to any responsibility for the fire risk assessment. In offering no evidence against the advisor, CFRS accepted that there was sufficient doubt as to whether his contract with the hotel included fire risk assessment services.

This is an interesting point whereby when employing the services of health and safety professionals it is important that both sides ensure they understand and document the responsibilities in a written agreement for avoidance of doubt and protection for both parties.

Attendance time of first appliance
The first call to the fire was received at 00.17.49; the caller stated that the fire alarm had gone off and he could see smoke behind the bar. At 00.21.58 a second call was received stating that the roof of the hotel was on fire; this call was made only three and a half minutes after the first and indicated a rapidly developing fire. The retained crews at Newquay were alerted at 00.18.16 hours and booked mobile to the incident at 00.24.59 hours. This appliance sent a ‘make pumps 4’ message at 00.26.45 hours followed by a ‘make pumps 5’ message from the first officer in attendance at 00.31.29. The actual time of the appliance booking in attendance may not be accurate in a situation when the fire control centre is taking multiple repeat calls. The introduction of mobile data terminals in CFRS appliances will include the facility for the appliance to book its status by the use of data transmission and not voice communication, which will ensure times are recorded accurately without the reliance of staff being available to answer the radio transmission.

Difficulties in pitching a ladder
The issue of parked cars in a busy holiday resort can be problematic for a number of reasons but due to it being a dynamic situation, it is unfair to speculate that the difficulties were unforeseen by the fire service when carrying out previous inspections. There are many hotels in Newquay that rely on street parking for their guests, and there would definitely be a conflict of interest for the owners of these hotels between restricted parking and emergency access.

Hydrants and water supply
The nearest hydrants to the hotel were on a 75mm spur from a 100mm water main which, given the size of the fire, would not be sufficient to maintain effective firefighting for a prolonged period. A 250mm water main is situated two streets from the hotel and hydrants from this main were utilised when resources allowed, providing an adequate supply of water for the purposes of firefighting. There were some additional problems encountered by the firefighters who attempted to access the nearest hydrants to the hotel as the pits were silted up. A review of the hydrant inspection programme has been undertaken which has resulted in key operational hydrants being maintained to a higher standard by the maintenance contractor

Second appliance
The report from Merseyside Fire and Rescue Service who carried out an independent assurance of the incident quoted:

“The management of retained staff and availability is an issue that occurs throughout the UK fire service; however there was sufficient resilience to deal with this incident.”

The management of retained firefighter availability continues to improve within CFRS, as the supplier of the electronic rota management system is developing the system in line with service requirements. Through a review of the emergency cover provision within the Integrated Risk Management Planning process, the service has introduced a flexible staffing model for Newquay to address the increased risk imposed by the population increase during the summer period. The station has two additional watches of staff allocated between May and September to provide a 24 hour crewed station with retained back-up. The availability of appliances and ridership levels form part of the performance management framework, which is reported to the informal working group of Cornwall Council’s Communities Overview and Scrutiny Committee.

Aerial Ladder Platform
The fact is that both Aerial Ladder Platforms (ALPs) were defective at the time of the fire and that contingency arrangements were in place with Devon and Somerset Fire and Rescue Service. The upper floors of the hotel were reached by the ladders carried on the appliances that attended the incident and the delay in an ALP attending had no significant impact on the outcome of the incident, due to the rapid rate and spread of fire development. The Service has since reviewed the replacement of appliances and in collaboration with Devon and Somerset Fire and Rescue Service, a joint procurement of aerial appliances has taken place which will provide improved interoperability between both services.

Fire escapes and fire certificate
Please note previous comments relating to the provision of the external escapes and the statutory bar.

Protection of light/ventilation well
Because there was no roof to the light well, it would, for the purposes of both AD B and the guidance to the FSO, be considered to be ‘open air’, and therefore there are no recommendations in either guide for elements that open or look out into the light well to have fire resistance.

Independent investigation?
Whilst in principle the point raised by Mr Cox may be worthy of debate, we do not believe in the case of the Penhallow Hotel there were any conflicts of interest, as the hotel had not been subjected to audit under the legislation for which the company were subsequently prosecuted. The responsibility lies clearly with the responsible person as defined within the Order.

In summary
It is fair to say that in responding to some of the points raised by Mr Cox we only just scratched the surface. There is no doubt that this tragedy has raised a significant number of issues for us as an organisation as well as the wider fire community. As a consequence we are currently developing a case study which we will be presenting in due course.

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