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Alan started his fire and safety career with Warwick County Fire Service in 1963 and served as both an Operational and Fire Safety Inspecting Officer. In 1976 he transferred to the West Midlands Fire Service until 1978 when he moved to the NHS as the District Fire Safety Officer for West Birmingham Health Authority where he was also the West Midlands Regional Health Authority Fire Advisor. During his NHS career he worked and studied for six months in the USA looking at different approaches to fire safety. He was also responsible for developing a computerized hospital fire evacuation program that was used in many major hospitals. In 1994 Alan moved to HSBC as its Senior Fire and Safety Officer responsible for the 80 countries in which the bank had a presence. During his career with HSBC he established a global approach to fire safety, organized many international fire and safety conferences, and developed a standardized method of protecting computer areas from fire. In 2005 he set up his own Fire and Safety Consultancy. During his career he has published a number of books on fire safety and made many specialist technical videos on subjects such as hospital evacuation, fire protection of electronic data protection areas, fire doors, and mail room safety. He has been awarded a Brooking NHS Travel Fellowship, Rospa Safety Professional of the Year (twice), FPA Premier Fire Safety Award, and The Prime Minister's Quality Initiative. He also contributes to many fire and safety journals including Fire, IOSH, Fire Surveyor, and Health and Safety Journal. He is a fully qualified Fire Service Inspecting Officer, member of the International Institute of Risk and Safety Managers (MIIRSM), Tech IOSH, and Qualified Fire Investigator. Alan has advised many large companies including the National Trust, Hospital Corporation of America (HCA), Kings College, Cambridge, Briton Hardware, BUPA, British Antarctic Survey Expedition, Chubb, Central Television, BBC, Radisson SAS, and the Falkland Islands Police.
March 13, 2023

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Hotel fire safety

Exclusive: The Cameron House Hotel Fire – What do we know & what do we still not know?

Fire Safety Consultant, Alan Cox, reports on his investigation into the 2017 Cameron House Hotel fire, where two guests died. The 122-page Fatal Accident Inquiry (FAI) report was released in early 2023, but still leaves many key questions unanswered, believes Alan.

Simon Midgley, 32, and his partner Richard Dyson, 38, from London, died in a fire at the five-star Cameron House on the banks of Loch Lomond on December 18, 2017, when a night porter emptied embers into a polythene bag and placed it in a cupboard which contained combustible items including kindling and newspapers.

I carried out this report at the request of Louise Adamson and Jane Midgley, the mother of Simon Midgley who felt that she did not really know why her son had died.

The Judiciary of Scotland has recently published a Fatal Accident Inquiry (FAI) report following the fire. Whilst this does provide a clearer insight into the fire and how the fatalities occurred, it still leaves many questions unanswered.

What we know about the Cameron House Hotel fire

The cause of the fire is almost certainly as described above, and it was fortunate that the actions of the staff were clearly shown on CCTV.

CameronHouseHotelFire-ALANOLIVER-AlamyStock-23

Smoke billowing from the fatal Cameron House Hotel fire in December 2017 (Credit: Alan Oliver/AlamyStock)


The FAI inquiry also revealed the following:

  • The careless disposal of ash in unsuitable receptacles and areas culminating in hot embers being placed within the concierge cupboard by the night porter.
  • The lack of a written Standard Operating Procedure re-enforced by staff training.
  • The absence of appropriate equipment for safe disposal of ash.
  • The full ash bins in the service area, and lack of a coherent system to regularly empty them, and the absence of instructions to staff when bins were full.
  • The presence of combustibles within the concierge cupboard, notwithstanding a warning that such should have been removed.

The following matters were found to be relevant:

  • A considerable delay in obtaining a guest list that caused a delay in carrying out an accurate roll call.
  • The alteration of the 2017 Fire Assessment Report by the appointed assessors to state that all the recommendations identified in the previous report had been recorded as complete without sight of evidence.
  • The presence and impact of hidden voids at the Hotel, in respect of the detection and spread of smoke and fire.
  • Building and Fire Safety Standards in respect of hotels, and the application of same to older buildings.

The Sheriff also made the following recommendations:

  • Owners/operators of similar hotels in Scotland should have up to date procedures and risk assessments to ensure that ash from open fires is removed and disposed in a safe manner.
  • Owners/operators of hotels or similar sleeping accommodation in Scotland should ensure that clear and robust prompt arrangements are in place to ensure that all guests are accounted for in the event of a fire and that other contingencies that may arise due to inclement weather are included.
  • Owners/operators of hotels or similar sleeping accommodation should ensure that robust arrangements are in place to ensure that all staff, including night staff, have experience of evacuation drills.
  • The Scottish Government should consider introducing for future conversions of historic buildings to be used as hotel accommodation a requirement to have active fire suppression systems installed.
  • The Scottish Government should constitute an expert working group to more fully explore the special risks which existing hotels and similar premises may pose through the presence of hidden cavities or voids, varying standards of workmanship, age, and the variance from current standards and to consider revising the guidance provided by the Scottish Government and others.
  • Scottish Fire and Rescue Service should reduce the period between a fire safety audit inspection and the issue of a written outcome report.

Prior to the FAI Cameron House had been ordered to pay £500,000 after admitting to breaches of fire safety rules.

A hotel porter has also been given a community payback order to carry out 300 hours of unpaid work.

The fire – Initial stages

06:39 – A pre alarm fire alarm sounded in the hotel reception area and staff responded, the night porter went to the floor above via the main stairwell and saw smoke at the end of the corridor. This information was given to the Night Manager who sounded the full alarm. Further checks found smoke coming from the Concierge Cupboard and this was subsequently opened, and an unsuccessful attempt was made to extinguish the fire. The Night Manager then called 999 and exited the building at 06.41 but forgot to take the guest list.

Guests then started to evacuate the building, but this proved very difficult for those in the main building and the escape routes were filling with smoke and gases. Guests in the modern part of the building were able to escape without any significant problems.

06:51 – The first Scottish Fire and Rescue Service (SFRS) arrived and observed smoke issuing from the main building and a well-developed fire within the upper ground floor where the Concierge Cupboard was located. The fire had also begun to spread to the floors above where the guest bedrooms were located.

On the first floor of the main building Rooms 6, 7, and 8 were on one side of a central library and Rooms 3 and 5 were on the other side. Rooms 2, 4, 10 and 11 were located on the second floor. Mr. Midgley and Mr. Dyson were guests in Room 8 on the first floor.

  • Room 10 Second floor – Guests unable to evacuate and had to be evacuated by 13.5 metre ladder by SFRS
  • Room 7 First floor, next to Room 8 – Guests tried to evacuate down the main staircase after seeing smoke come under the door and through sanitary ware 30 seconds after the alarm started. When they got to reception, they saw the Christmas tree was on fire and could see smoke on the stairs and decided to turn around and go back.
  • Room 6 First floor – Guests evacuated and found other guests from Room 7 and heard a staff member calling from outside a side door and went in that direction and exited the building.
  • Room 5 First floor – Guests awakened by fire alarm and on opening door into central library were confronted by dense black smoke and had to crawl to stay below smoke. They went towards main reception down staircase and realised they could not go in that direction and searched around central library and found a door that they went through where there was no smoke and met other guests from the newer part of the hotel that were unaware of the situation. They then exited the building.
  • Room 3 Second floor – Guests in this room were fortunate as their room was separated from other first floor rooms by the doors to the central library and there was no smoke in their room or in the outside corridor, but they could see the smoke and flames through the glass in the door and they were able to leave and exit the hotel in the other direction.
  • Room 4 Second floor – Guests in this room opened door after being awakened by the fire alarm and seeing and smelling smoke that was not very thick. After leaving their room and descending a few steps they heard a member of staff shouting who then lead them out of the building.
  • Room 2 Second floor – Guests awakened by the fire alarm saw smoke in room and used direct access to an exit and left the building.
  • Room 11 Second floor – Guests opened door after hearing fire alarm and saw smoke in corridor, they went in the direction of the smoke as there was no alternative exit but had to turn back. Guests were a little confused until they were escorted out by a member of staff.
  • Room 10 Second floor – Guests opened the door following being awakened by the fire alarm to find thick smoke that prevented them leaving their room. The called the emergency services who later rescued them by ladder who were then taken to hospital.
  • Room 8 First floor – This is the room that the two guests that died were staying, and their bodies were found on the second-floor landing.

Cameron House Hotel report by SFRS

CameronHouse-Fire-21

Image from STV news: Cameron House Hotel Fire

A report by the SFRS concluded that the fire had originated within the concierge cupboard on the upper ground floor and had spread within the cupboard to fully involve the contents.

Once the cupboard was opened this enabled a well-developed fire to spread outward into the entrance foyer, reception area and beyond.

The fire continued to spread within the various wall and ceiling voids situated throughout the Grade B listed building. Further fire development beyond the Grade B listed building was halted as a result of the firefighting actions taken by the attending fire crews.

Evacuation of the hotel, assembly, and roll call

A representative of SFRS explained that the incident commander would normally be met on arrival by the duty holder of the premises. This duty holder could be the owner or manager, but they should have some responsibility for the premises. A duty holder should be fully aware of the premises fire risk assessment, fire evacuation plan, how to raise the fire alarm if required, and be able to provide the SFRS with an accurate roll call.

The duty holder should be aware if persons are unaccounted for. They would find out if persons were unaccounted by taking a roll call at the assembly point and the duty holder should then report that back to SFRS. The responsibility to ensure that a roll call is undertaken is placed on the duty holder. The duty holder has responsibility for evacuation and roll call. Rescue is the responsibility of SFRS.

The importance of the availability of an accurate roll call was emphasised as it was important to the tactical plan for entering the building for the purpose of search and rescue.

What we don’t know about the Cameron House Hotel fire

Like many reports that are published following serious or fatal fires they raise more questions that need answering if we are to truly learn from what happened. This is the reason that this information needs to be in the public domain.

With this fire we are almost certain that we know how the fire started, but not how the fire spread so rapidly through the hotel. Whilst SFRS has indicated that this was due to hidden voids, I have to  ask, “What action was taken prior to the fire to prevent the spread of fire and smoke through these hidden voids?”

When, I start to look at these serious or fatal fires I ask myself… How did the SFRS, the Duty Holder and the Fire Risk Assessor determine that the hotel was safe for people?

Did they consider the definition of means of escape that I was given at the start of my career? “Structural means forming an integral part of the building whereby people can escape from fire by their own unaided efforts to a place of safety.” Clearly in my view, if they did – it is unlikely that we would have seen this outcome.

Hidden voids, cavities and wall linings

It is unfortunate that in many of these incidents we have to put the blame on hidden voids for the spread of fire. As soon as any professional fire risk assessor comes into contact with buildings like this, they should know immediately that this is something that must be taken into account to make the building safe.

It was the same with the Royal Clarence Hotel Fire, where blame was attributed to hidden voids by the FRS. Again, in the Clandon Park Fire partial blame is attributed to hidden voids and this is a National Trust building.

The FAI Report does not contain a great deal of information from those concerned on this aspect but reference to this document from the Scottish Government does give some useful guidance in respect of hidden voids, it states:

Fire Spread through Cavities

  1. Many buildings have cavities and voids, sometimes hidden from view, which may allow smoke and fire to spread. Examples are:
  • vertical shafts, lifts and dumb waiters
  • false ceilings, especially if walls do not continue above the ceiling
  • voids behind wall panelling
  • unsealed holes in walls and ceilings for pipe work, cables or other services
  • a roof space or attic
  • a duct or any other space used to run services
  1. Potential fire spread through cavities and voids should be assessed and, where practical, examined to see if there are voids that fire and smoke could spread through.
  2. Cavity barriers may be necessary to restrict the spread of fire in cavities, particularly for those cavities that could allow fire spread between compartments.

So, was this guidance followed and was any work done to prevent the spread of fire and smoke prior to this fateful fire?

I have dealt with several buildings before and found that by making enquiries to the maintenance staff it is fairly easy to establish the location and extent of many voids and openings, as they often use them for installing pipework and wiring. Where this is not possible, and I have not been certain about the fire compartmentation, I have recommended that rooms are taken out of use for sleeping – this quickly focuses the attention of the owner to rectify the problem.

A compartmentation survey can also help identify these hidden voids using Ground Penetrating Radar (GPR) and Infrared detection methods, together with HD Videoscope equipment. If we can detect hidden voids in pyramids using scanning technology – we can certainly use it to detect these voids in buildings.

There is certainly a lack of information in the FAI that gives me any confidence that this work was undertaken prior to the fire – if it was, it certainly did not stop the rapid spread of fire and smoke. Another aspect that has not received a great deal of exposure is the amount of timber cladding to walls and I have to ask if any precautions were taken to stop the spread of fire in this area of concern?

Fire alarm and automatic detection

There is now a lot of reliance on fire alarms and automatic fire detection. Whilst this may be appropriate for building protection, I feel that where life safety is concerned, sole reliance can be dangerous and I am often reminded by the term “it is of little help hearing the fire alarm if you can’t get out of the building”.

Aico-FireAlarm-21From the FAI we are informed that the hotel had an addressable fire alarm system and from the many reports it appears that audibility levels were satisfactory. Yet, we are not informed if the system was checked to establish how the system tracked the spread of fire.

Means of escape

This is the crucial aspect in this fire, and it would have been helpful if the FAI Report contained plans and photographs to highlight the problems and escape routes. Clearly, without plans it is difficult to be able to evaluate escape routes and exits and why the fire and smoke spread so quickly. However, it does appear that certain guest rooms opened into the Central Library – Room 5 on the first floor – “on opening the room door to the Central Library they were confronted with dense black smoke.”

Also, without additional evidence it is impossible to establish if the fire resisting doorsets performed as required, were correctly positioned/closed and if the ground floor was adequately separated from upper floors. This could be a key factor in this fire and could have contributed to the rapid spread of fire and smoke.

SFRS firefighting and rescue operations

Unfortunately, there is not a great deal of information contained within the FAI to establish how effective the operational procedures were but from the stated facts there did not appear to have been a shortage of manpower, appliances or water, and several rescues are described in the report.

Conclusions: “Another fatal fire that should not have happened”

This is another fatal fire that should not have happened if the right level of fire safety had been in place. Whilst it is difficult to be able to establish the exact cause, due to the lack of detail and information, it is clear from the outcome that once again the unsuspecting members of the public have paid a high price.

We almost certainly know how the fire started and we have information that tells us that the fire probably spread through hidden voids and cavities, but no information that informs us if these were previously identified and if any remedial action was taken to prevent this foreseeable problem.

From my previous articles it will be clear that I would like to see more open honest and transparent information from fire and rescue services so that we can all learn from these tragic incidents. I also feel that this can only be achieved by a truly independent organisation that has no vested interest in the outcome.


Footnote: I have carried out this initial investigation at the request of Louise Adamson and Jane Midgley the mother of Simon Midgley who felt that she did not really know why her son had died and whilst we still know some of the factors, I believe that there is still a lot more that we need to know.

I was hoping to include more details about the past history of the fire safety measures that were in place, but two Freedom of Information requests to the Scottish Fire and Rescue Service have both been refused. This was part of the latest notice: “The Scottish Fire and Rescue Service (SFRS) have, as required given consideration to the public interest test. With this SFRS considers that there is a substantial risk that the outcome of any ongoing investigations and any court proceedings could be significantly prejudiced by the disclosure of the information and as such the public interest is weighed against its release.”

I find this a very interesting statement, as the mother of one of the deceased would like to see this information in the public domain. As would many other fire safety professionals, no doubt. The hotel has been ordered to pay £500,000 after admitting to breaches of fire safety rules and a hotel porter has also been given a community payback order to carry out 300 hours of unpaid work.

So, what on-going investigations and court proceedings do they have in mind? Perhaps they may be worried that they may find themselves in a difficult position if they disclose all the known facts?

 

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