Robert Ratcliff

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Rob Ratcliff was the Content and Community Manager of IFSEC Global.com. He is a self-confessed everyman in the world of security and fire, keen to learn from the global community of experts who have been a part of IFSEC for 40 years now.
April 2, 2013

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Lakanal House Verdict: Deaths Were Avoidable

The jury in the inquest into the 2009 Lakanal House high-rise flats fire returned their damning narrative verdicts on the deaths of six people last week.

The Southwark Council, the London Fire Brigade, and 999 Operators were all heavily criticised for the events that led to the deaths of Catherine Hickman, Dayana Francisquini and her two children, and Helen Udoaka and her three-week-old daughter.

Control operators failed to listen
The jurors concluded that the evidence suggests Hickman “would have been able to escape without assistance,” but operators repeatedly told her to stay in the flat.

There was a clear expectation by Brigade Control operators that persons trapped would be rescued by firefighters.
Their advice to the caller relied heavily on this assumption.

Brigade Control officers “failed to promote active listening” in their training of operators. Also, “evidence suggests that existing training documents are contradictory and inconsistent, particularly in regard to either ‘staying put’ or ‘getting out’ when there is a fire in the building.”

Response to initial fire
The jurors concluded that the response from firefighters to the initial fire in flat 65 was “both adequate and timely,” but serious failures in compartmentation of the building caused the fire to spread far faster than they expected.

The fire spread from flat 65 to Hickman’s flat via the panels under her bedroom windows, which had been replaced with PVC following the removal of asbestos. Southwark Building Design Services (SBDS) was instructed to check the work for fire safety, but the work was not checked. These alterations “may have made more than a minimal contribution to the death of Catherine Hickman.”

Fire risk assessment
Fire was able to enter flat 81, where Fancsiquini, Udoaka, and their children died, because neither the boxing in under the stairs nor the panel above the flat door provided adequate fire resistance. There were no fire seals on the front door, and “there was a lack of fire-stopping on internal pipework from previous renovations.”

As we discussed last month, a fire risk assessment had not been carried out, as was required by the Regulatory Reform Order. Jurors wrote of numerous opportunities to remedy these failures:

Had a fire risk assessment been carried out at Lakanal House, it is possible that these features may have been highlighted for further investigation.
The installation of a new hearing system in the 1980s would have been an opportunity to ensure that the fire-stopping around pipes leading into Flat 81, and segmentation within the suspended ceiling offered adequate protection from fire.
The 2006/7 refurbishment provided numerous opportunities to consider whether the level of fire protection was adequate.

Confusion over the building’s layout also contributed to the deaths. Firefighters struggled to find the victims, and residents did not know the east balcony of the building offered an escape route. The balcony led back the central escape staircase, and jurors concluded that the five people who died in flat 81 could have escaped unaided in the first hour after the fire started. They died in the flat shortly before firefighters reached them.

Recommendations
Frances M. Kirkham, the coroner who investigated these deaths, offered recommendations to Communities Secretary Eric Pickles.

  • Review “the ‘stay put’ principle and its interaction with the ‘get out and stay out’ policy.”
  • Provide “consolidated national guidance” on high rise firefighting.
  • Encourage sprinkler system retrofitting, which “might now be possible at lower cost than had previously been thought.”
  • Offer clear guidance on the definition of “common parts,” and to recommend “inspections of a sample of flats or maisonettes to identify possible breaches of the compartment.”

Kirkham also wrote letters to the London Fire Brigade, the Southwark Council, and the Fire Sector Federation. The FSF said in a press release Saturday:

The Fire Sector Federation (FSF) wishes to express profound sadness for the tragic loss of life that occurred at Lakanal House on the 3rd July 2009.
The incident and subsequent investigations have highlighted a number of areas for improvement to ensure safety from fire in the future and the FSF is committed to working with partners from across the sector to secure those improvements and find future solutions.

The narrative verdicts and Kirkham’s reports can be read in full on the Lambeth Council’s website.

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safeNsaneRob RatcliffShehsaulsherrybatye Recent comment authors
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Sheh
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Sheh

In most of the high rise buildings fire evacution is one of the trickiest jobs. Elevators are jammed…people dont have enough time and energy to use stairs. Rescuers are finding difficult to access the victims…The situation gets into vicious circle. ‘Stay put’ principle surely needs revisting and people are required to be educated on that. The critical moments lost can cost numerous lives. High rise buildings can be designed in such a manner that emergency exits are available at all flats. The designers can contemplate certain external arrangments which could faciliatate expeditous extrication. 

batye
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batye

could not agree more… most of the time high rises in case of three alarms fire becomes death traps… as even with new technology and design you still have a flow…

Rob Ratcliff
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Rob Ratcliff

I think I generally disagree. The stay put principle for me is quite a sensible one, if counter-intuitive. Elevators are obviously a no go during a fire, leaving only stairwells and (in some cases) external fire escapes attached to the building. If a flat has proper compartmentalisation then the fire shouldn’t spread for at least 60 minutes. If everyone evacuates all at once you risk a stampede, and you’ll actually get in the way of firefighters attempting to get in. This is the rationale behind the principle. Obviously, where compartmentalisation isn’t up to standard, as it wasn’t in Lakanal, then… Read more »

saulsherry
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saulsherry

Yep, it’s worrying. I know there’s a lot being done with data mining to determine unsafe buildings through water/power consumption/heat production etc – if they are over populated its a sure sign of poor compartmentalisation. But this tends to be happening in major cities in wealthy countries, leaving the rest of the world open to disaster.

Rob Ratcliff
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Rob Ratcliff

Interesting. But really we shouldn’t need data mining for this kind of insight. Building owners should carry out regular, professional, inspections, pretty much as simple as that. Neither tactic will help much in developing countries, where the death toll always seems to be worse. This was England’s worst high-rise residential tragedy, and we can be relatively thankful that the death toll was only six. Compared to some of the cricket score tragedies we hear about so often, this isn’t much. But it does of course make it no less tragic and needless. All six, we know now, could have survived.

safeNsane
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safeNsane

@Rob, I think you hit the nail on the head, when everything is done right the stay put principle works.  In this case though the ball was dropped by multiple people before the fire even started.  What the dispatchers didn’t know came back to haunt them.  I know you mentioned active listening but I don’t imagine too many of the calls they got were calm cool assessments of the fire’s spread.  Most people don’t have it in them to stay calm and explain exactly what is going on in a situation like that.

Rob Ratcliff
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Rob Ratcliff

In most situations I’d agree with you, but having read the transcripts of the phone call that Catherine Hickman made, her assessment of the situation was rational and clear. She was on the phone to the operators for at least 30 minutes before she passed out. It’s harrowing testimony, but I can’t find it right now, as there was almost 60 days of evidence at the inquest.

safeNsane
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safeNsane

@Rob, I had not heard that or heard the audio from the call.  It sounds like the system really let her down from beginning to end.  Did the experts testifying give any indication as to if she could have safely made it out on her own?

Rob Ratcliff
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Rob Ratcliff

Yes they did. They said she certainly could have escaped on her own, up to a specific point in time that has slipped my reference now. Which is really tough to hear, as she was only doing what she was told and what, in any normal circumstance where the fire resistance in the flats was satisfactory, would have been the right thing to do.

safeNsane
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safeNsane

@Rob, thanks for the insight, that really is sad and thought provoking. The article mentioned that there were some training issues and that the talk about active listening really hits home knowing that she could have made it out safely.

Sheh
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Sheh

@Rob…In my understanding…if people are made to think on the rut of wait and see….things might not turn in their favor. In case of stay put principle …we are waiting for external agencies to come and rescue us without resorting to our own intiative which are best suited accordance to prevailing situations. It is quite possible that the victims are unable to mould the situation to their advantage but the thinking process should not stop in that bargain. In the past, we have examples where some intrepid people who found themselves engulfed in flames not only improvised ways to get… Read more »

Rob Ratcliff
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Rob Ratcliff

Indeed you’re right, but then we’ve also seen stories where have-a-go heroes have entered a fire to save someone and ended up dying or nearly dying themselves, along with the person they were trying to save. So there are of course always two sides to every coin. Probably more than two.

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