The Cathedral Yard fire

Royal Clarence Hotel fire: The HSE report – like the fire service report – fails to answer the key questions

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Fire-safety consultant

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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.
September 5, 2018

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In the aftermath of the fire that gutted the UK’s oldest hotel, the Royal Clarence Hotel, I raised a number of questions that needed answers.

Then in March this year I posed further questions about the Devon & Somerset Fire & Rescue Service (DSFRS) report into the fire.

Unfortunately, few of these questions have been answered and there remain many areas of concern.

These were the key areas that I raised initially:

  • What was the cause of the fire?
  • Why did the fire spread to the Royal Clarence Hotel?
  • What can we learn from this tragic incident?

The report into the fire failed to answer many questions I raised and only gives me more concern about the accuracy of serious fire investigations carried out by an organisation with a vested interest in the outcome. It is not clear there is sufficient transparency to ensure that protect the public interest.

The key unanswered questions:

  • What actions were taken by DSFRS following the discovery of hidden voids in the Royal Clarence Hotel (RCH) in 2015?
  • What actions were taken prior to the fire to prevent fire spread from adjacent buildings to the RCH?
  • What recommendations were made at the planning stage to prevent fire spread from No 18?
  • Why are different times indicated for when the incident was declared a “major incident”: 5.21am and 5.42am?
  • Why was it thought that the fire was under control at 6.53am?
  • What firefighting actions were undertaken between 6.53am and 10am approximately for the fire to suddenly spread to the RCH?
  • Why was there no reference to the window in room 402?
  • Why is there no reference to the fire risk assessments (FRA) for the buildings involved?
  • What have we learnt from this fire?

I have now looked at the Health and Safety Executive’s (HSE) role in assessing the fire and this also raises serious concerns.

HSE Timeline

This is the HSE timeline of events following a Freedom of Information (FOI) request to the HSE about communication between DSFRS, building control (BC) and English Heritage (EH), both before and after the event.

  • 28/10/2016 – Start of fire
  • 31/10/2016 – Request via HSE duty officer for input into ongoing fire involving RCH regarding asbestos and cordons.
  • 31/11/2016 – Email sent to Police and Fire regarding investigation and HSE enforcement of RRO on construction sites.
  • 1/11/2016 – Telephone conversation with Exeter City Council about proposed demolition.
  • Email from redacted – advising no suspected criminality. Investigation to be handed over to redacted
  • 2/11/2016 – Phone call from Senior Fire Officer (Business Safety Manager) agreement enforcement lies with HSE. Discussed requirement for fire service investigation. Contact made with redacted
  • Meeting with redacted fire investigator DSFRS, Lines of enquiry, Agreement to take witness statements from site manager, Cause of fire likely to be inconclusive due to extent of fire by time of fire service attendance, Information that hot works undertaken at site on day prior to fire.
  • 3/11/2016 – Phone call from redacted arranged for Wednesday 9th November at DSFRS HQ
  • 7/11/2016 – Briefing line manager – scope of investigation. Telephone contact with redacted, Confirmation workers on site day before incident, Timings confirmed, and methods of working discussed. Also spoke to welder redacted arrangements made to take witness statement from him on Fri 11th Nov
  • 9/11/2016 – Voluntary statement from redacted site supervisor redacted
  • 11/11/2016 – Voluntary statement from welder
  • 21/11/2016 – Ongoing enquiries NOC’s sent to Client, Principal Contractor & Principal Designer.
  • 13/12/2016 – PD redacted reply to ongoing NOC request. Email to redacted requesting response. Email reply stated that it should have been received – to be resent when back on line – in a few days.
  • 21/12/2016 – Email report from redactedredacted (PC) responses to HSE queries
  • 9/1/2017 – Email to redacted requesting response with regard to client ongoing enquiries NOC and reminding about reporting incident under RIDDOR

Parts of the timeline not specifically related to this investigation were omitted.

The DSFRS report into the fire states that in this respect:

“The CDM Regulations are for buildings that are under construction, any responsibility or powers for Fire and Rescue Services to inspect for fire safety regulations adherence in respect of a construction site which is contained within or forms part of premises occupied by persons other than those carrying out construction work, or any activity related to this work is removed. The Regulations inspecting body is the Health & Safety Executive.

“Due to this DSFRS did not have any enforcement or inspection responsibilities of the building works being undertaken in number 18 (origin of fire) prior to the fire occurring.”

As seen in the HSE timeline there does not appear to have been any discussion or agreements in place with DSFRS prior to the fire. While there may not have been any direct involvement there were liaison responsibilities together with observations and comments at the planning stage. Given the historic nature of this area and the RCH, I would have expected this to be given a high priority.

There is reference in the HSE report to welding carried out the previous day and the area where this work was undertaken is shown, although strangely enough there is no reference to this in the DSFRS report.

The HSE report shows that the hot work was completed by 11am and the welder remained on site until 3pm and reported no signs of fire or smoke.

It is also reported that the site manager left the site at 7. 30pm. The report also points out that no issues were identified with the procedures implemented by redacted in relation to hot works undertaken on site on 27 October 2016.

It is interesting to note that the HSE Report has no mention of a fire risk assessment but refers only to a fire plan – in my understanding something entirely different.

The other interesting point is that the report states that “the fire plan document was documented but has not been seen as part of the investigation apart from a photograph of a notice board and a verbal description by the site manager of the arrangements in place – eg number of fire extinguishers, means of raising the alarm in the event of fire, implementing and review of fire exit routes, no smoking on site etc.”

When I asked the HSE for a copy of the fire risk assessment I was directed towards their report that does not specifically refer to a FRA. HSG168 clearly states: “Legislation requires a suitable and sufficient fire risk assessment to be carried out by a responsible person (the employer or persons in control)”.

Why no reference to a fire risk assessment in either report?

So why is there no reference to a fire risk assessment in either report and is the loss of important documentation a valid excuse for not producing it after a fire?

The HSE Report appears to dismiss hot work as a possible cause but my experience and research has shown me that smouldering fires can burn for very long periods and a number of serious fires have occurred many hours after hot work has ceased – so should this possible cause have been so easily dismissed on the statements of persons with a vested interest.

In respect of arson the report states: “Measures for prevention of arson at the site were also considered, the scaffolding was erected to prevent unauthorised access, the windows at the front of the property were boarded over, full security fencing utilising 1800mm high fencing which installed that was properly secure and lockable points of access were provided.

“The lockable entry points were reviewed after redacted left the site and this led to the locks being changed.”

When I asked the HSE what action was taken to protect the escape route along Lamb Alley (the access route between the buildings) they replied “HSE holds no information”. This was the same reply they gave to the following important questions:

  • Was any information obtained from the previous contractors that were replaced shortly before the fire?
  • What actions were recommended or required to prevent the fire spread from No 18 to adjoining properties?
  • Was the Health and Safety File available and inspected?
  • Was the Construction Phase Plan available and inspected?

Conclusions

Having had the chance to examine both reports from DSFRS and the HSE it is my opinion that many questions still need answering if we are to learn from this tragic fire.

I remain unconvinced that best practice was followed both before and during the fire. I believe this was a major contributory factor in the loss of the Royal Clarence Hotel.

Two anonymous phone calls from persons with a credibly strong insight into what happened have convinced me that much more information has yet to be disclosed

And receipt of two anonymous phone calls after my article and the BBC investigation from persons with a credibly strong insight into what happened during the fire, have convinced me that much more information has yet to be disclosed.

During my investigation into the Penhallow Hotel Fire I was pleased that Cornwall FRS took the time to respond to my findings. They concluded: “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.”

They also added that independent investigation was worthy of debate.

I was also pleased to attend the case study developed. While it did not reflect many aspects I had outlined in the article, at least the importance of the fire was not lost.

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Robert Molson
Robert Molson
September 6, 2018 9:07 pm

Were you aware that the HSE had visited number 18 only a few days earlier following a call from me regarding unsafe demolition procedures.

Alan Cox
Alan Cox
September 7, 2018 11:42 am
Reply to  Robert Molson

No, I wasn’t – are you able to discuss in private?

Alan Cox
Alan Cox
September 10, 2018 8:00 am

No, I didn’t know that – could we discuss in private? Thanks

brett johnson
brett johnson
November 20, 2018 7:11 am

do you have a link to this HSE report please ?? – i’m looking on line but so far can’t find any reference