In depth

FRS report into Royal Clarence Hotel fire is full of holes – this is what’s missing

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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.
March 15, 2018

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I always look forward to the publication of any report looking at serious fires and this was no exception.

A report into the Royal Clarence Hotel fire has just been issued by Devon and Somerset Fire and Rescue Service (DSFRS). Across 50 pages it covers many areas including the history of the  and the relevant regulations, prevention and protection visits, health and safety principles, fires in heritage buildings, the incident, statistics and recommendations.

Unfortunately, whilst at first sight this looks like an interesting report, when you read it in detail it soon becomes apparent that many key issues are not covered – including the cause of the fire, information from other stakeholders including the HSE, building control, insurers, contractors/architects and witnesses.

In any incident of this nature the information from these key people/organisations is vital if an accurate overview of the incident is to be provided.

For many years I’ve found FRS reports have consistently been one sided and have not, in my opinion, given a true picture of what really happened

For many years I have found that reports from Fire and Rescue Services (FRS) have consistently been one sided and have not, in my opinion, given a true picture of what really happened. Whilst I understand why this happens, it does not allow the wider community to learn what really went wrong. This is why I feel that we need an independent investigation for incidents such as this.

Some years ago I was lucky enough to study fire investigation in the US and their use of a ‘mapping’ system for this type of investigation. I was quite surprised at the very positive outcomes it produced and whilst it needed a lot of work, it certainly proved its worth.

I have used this system on a number of occasions and it has proved extremely useful. One report into a fatal fire on the Falklands Islands, carried out by a HM Fire Inspector from the Home Office, concluded it was an accidental fire.

The mapping system identified one person with the opportunity to start the fire and I worked with the Falkland Islands Police to get the case reopened, so the value of good fire investigation should not be overlooked.

 

  1. Introduction to the Cathedral Yard Exeter report

In the introduction the review states that it is provided on behalf of the Devon and Somerset Fire and Rescue Authority by DSFRS and is aimed at providing the communities of Devon and Somerset with facts around the incident in response to several requests made to the service.

I thought this was an unusual statement because I know there will be many individuals and organisations outside the geographical area that would be interested in the report, in the hope that we can all learn about what happened in order to prevent similar occurrences.

  1. Executive summary

The Executive Summary (ES) gives a brief overview of the incident from the first call to a fire at 18 Cathedral Yard at 05.11 on 28 October to 14.30 on the 7 November 2016 – a period of 10 days.

There is also a statement in the ES that states: “The fire spread undetected through voids and other channels throughout the hotel leading to the sudden development of the fire.” As this has an important bearing on the fire I will discuss it later.

The ES concludes with the following: “This was an exceptional and unfortunate incident and there is no evidence to show that the management and staff of the RCH could have done anything more, and due to their actions there were no injuries to the guests. This was formally recognised and the staff members received the Chief Fire Offcer’s Certifcate of Commendation for their actions on the night of 28 October 2016.”

  1. Context, review and history of RCH and neighbouring buildings

The next three sections contain general information about the buildings involved, their history and how DSFRS is a learning organisation. There are also some interesting photographs showing how the fire may have spread at roof level.

  1. History of relevant regulations

This section contains an overview of the relevant regulations relating to fire safety including the Construction Design and Management Regulations and in this respect the DSFRS report makes the following statement: “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.

HSG 168 Fire Safety in Construction. Guidance for clients, designers and those managing and carrying out construction work involving significant fire risks.

“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.”

While in strict legislative terms this may be true – consider guidance published by the HSE Fire Safety in Construction Sites – there are numerous references to the FRS’ role, including:

“Construction sites are also covered by the Fire and Rescue Services Act 2004 (in England and Wales) and the Fire (Scotland) Act 2005 in providing Fire and Rescue Authorities responsibilities to respond to fire and other emergencies to protect life, the environment (including animals) and property. These responsibilities include:

  • The right to access water supplies and enter premises where they reasonably believe a fire or other emergency has occurred.
  • To take such action as they consider appropriate to prevent and limit injury and loss.
  • To obtain information needed to enable the authority to discharge its functions; and
  • To investigate the cause and extent of fires.”

The client, designer, CDM coordinator and principal contractor should also consider how they will assist the fire and rescue authorities in the discharge of their duties under the Fire and Rescue Services Act 2004 (in England and Wales) and the Fire (Scotland) Act 2005.

In any case, notice should be given to the F&RA of any intended works affecting the water supply and/or fire hydrants. But liaison is also appropriate to inform the F&RA of the nature of the work and the access facilities to be provided, including for fire appliances.

There is no reference in the DSFRA report to this and if this happened or if DSFRS visited No 18 to obtain any information which given the significance of the risk I would have thought should have been undertaken.

Other legislation includes:

  • The Regulatory Reform (Fire Safety) Order 2005 (FSO) in England and Wales;
  • The Fire (Scotland) Act 2005 (FSA) Scotland;
  • The Dangerous Substances and Explosive Atmospheres Regulations 2002 (DSEAR)
  • Fire Safety (Employee’s Capabilities) (England) Regulations 2010. (These Regulations apply in England only. They require that employers must take account of an employee’s capabilities as regards fire safety in entrusting tasks to them.)

There is also no reference to any Fire Risk Assessment (FRA) that was carried out for No 18 or any requirements imposed by the HSE/Building Inspector/Insurance Company, which again I think, are important omissions from the report.

There is also an important section in the HSE guide that covers the following:

Liaison with the fire service may be relevant, especially on large sites or if any of the following applies:

  • There is a substantial risk to the public, e.g. where fire may result in the need for large-scale evacuation of heavily occupied neighbouring areas. (I think that the RCH would meet this criteria)
  • Large or high fire risk structures are built close to other occupied premises.
  • There are particular risks posed to fire fighters, e.g. the presence of large numbers of gas cylinders or flammable liquids on site, timber frame structures, unusual construction techniques and basements or underground structures such as tunnels. (Was any of this applicable?)
  • There are highly flammable materials – consider HAZMAT warning signs for information of the fire service.
  • The fire service’s access to the site may be limited, ie if access roads are narrow and congested or there is no access available to one side of a large site. (Access was certainly limited)
  • Water supplies are limited or do not exist, e.g. a large factory development in a green field site.
  • Work takes place above 18 m (specialist access equipment may be required) and anywhere else where specialised rescue equipment may be needed, e.g. tunnels.
  • Sleeping accommodation is provided for construction employees.
  • Occupied buildings with large or high-risk occupancy are undergoing refurbishment.
  • New buildings are undergoing partial occupation before completion (especially where the partial occupation is for residential use).
  • The construction of timber-framed buildings creates a heightened risk of a fire spreading beyond the site to neighbouring buildings. (This was certainly true)

The last point is especially pertinent given the construction of these buildings and this comment in the report “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.” is I feel very misleading.

  1. Prevention and protection visits

In the section of the report relating to Prevention and Protection visits it states  “Prior to the fire, DSFRS had undertaken site visits to the RCH with the last being on the 7th December 2015. Site Specific Risk Information visits identified numerous firefighting risks within the RCH, such as hidden fire travel due to voids; dumb waiters and porters staircases as well as risks associated with numerous older buildings being merged together to form the larger hotel.

There were also however a number of voids that the crews and hotel management knew would be within the property, but they were unable to identify the specific location without causing significant damage during familiarisation visits.”

This statement poses many questions that I feel need answering and include the following:

  • Were these findings formally made known to any other parties e.g. the owner, Building Control and were they made available for the attending operational crews?
  • Was any further investigation recommended e.g. non-invasive identification of hidden voids?
  • Was this knowledge included in the CDM Plan for No 18 and if not why?
  • Were these findings included in the FRA for the RCH?
  • Did the original Fire Certificate identify these problems?

Again these are very important questions that need to be answered together with clarification about the statement “unregulated building adaption took place which would not meet modern regulations” – what exactly does this refer to?

  1. Legislation

This section looks at legislation in respect of firefighters and health and safety principles.

  1. Fire-related issues with heritage buildings

The problems outlined in this section are well known as they have been identified in many previous fires and because of this special attention should have been given to these alterations and of course we are informed that the problem of hidden voids had been previously identified by DFRS so it should not have come as a surprise to them during fire fighting operations.

More importantly is what action was taken to identify and protect these voids when they were found and the report gives us no information on this.

  1. The incident

Please note that some of these observations do not appear in the report but are available on social media.

05.11 First 999 calls made to the DSFRS – This witness that took the first photograph was woken up by the noise and flames from the fire and went to try and get out but could not open one of the doors so he went back to get his key card. In the meantime his partner had managed to open the door and on their way out another guest activated the fire alarm.

05.13 The RCH guest that took one of the earliest photos in the report at 05.13 appears to indicate a fully developed fire within No 18 that was also at the rear of the RCH but it is difficult to see from the ground floor to what extent this affected the hotel.

05.18 First appliance arrives at scene of fire.

05.21 The report states “At 05:21 the incident commander (IC) contacts fire control and declares a ‘major incident’.

This is interesting as on the DSFRS website it states: Where did the fire start?”

The fire started in the building at 18 Cathedral Yard in the early hours of Friday 28 October 2016. The Service received the first 999 call at 5.11am. The incident was declared a major incident at 5.42am – so which one is correct?

06.53 Another photograph that was taken at 06.53 shows that the fire in No 18 appears to be under control and this is confirmed in a report in The Telegraph that states  “Crews initially thought they had it under control but later it has spread to other venues on the Cathedral Green – including the historic Royal Clarence.”

10.00 (approx.) An on site BBC Reporter stated “It looks like the fire was contained – but that changed – a gust of air just after 10am caused the fire to spread across the RCH rooftops.”

In another interview with the guest that took the first photographs who was an architectural designer he points to the wall between No 18 and the RCH and points out the timber frame. When he was asked about the fire spread to the RCH he indicates that this happened at about 10.00 at roof level and in his opinion the fire spread could have been prevented.

Clearly, there are some areas of concern here that I feel need additional clarification together with a detailed explanation of how a fire that at one point was thought to be under control managed to spread to the RCH.

  1. Report recommendations

The first recommendations in the report relate to the provision of fixed fire fighting and detection systems but strangely enough there are no recommendations for improving fire separation that should in my opinion be a first consideration.

The second part of the recommendations relate to a review of CDM Regulations but in my view the guidance already exists so I find this confusing.

  1. Area of concern

 It is always very difficult trying to determine some of the answers to why these fires occurred and how they spread when you have never visited the building, were not there and don’t have access to the people involved but whilst carrying out this investigation I did come across this area of concern.

Prior to 1871 there used to be a passageway between the two buildings (Lamb Alley) but around this time changes were made that incorporated this alley into No 18 Cathedral Close and this appears to have become a “service corridor” that appears on both the drawings in the report and the plans for No 18.

The alterations that were in place at No 18 when the fire occurred show windows at each level and pavement lights for the basement area and clearly any fire in this area could, given the right conditions, quickly spread to the Royal Clarence Hotel.

In addition to this the plans show rubbish bins adjacent to the windows on the ground floor, although it is difficult to substantiate this, as scaffolding/sheeting appears to have been in place at the time of the fire. It was also noted that the plans showed that domestic sprinklers were to be installed in the basement together with a “fire mist system” to the four floor.

The proposed plans also show another “light well” at 3rd floor level that also appears to serve the RCH but there is no fire resistance shown – this is concerning as it serves a kitchen and lounge in the new development.

Looking at the plans in the DSFRS Report it appears that this alley was also an “escape route” for the hotel and the lines of fire resistance (in red) appear to substantiate this.

In my experience combining escape routes and rubbish disposal areas is never an ideal solution and when this is also in a “light and ventilation well,” this is a recipe for disaster unless the area is well managed and protected against fire spread because it can also be a convenient staff “smoking area”.

This was the statement from one of the guests in Room 402 that did not appear in the report:

“And the question that puzzles me is really why a window remained that was looking out on the gallery roof [see image below], when the plans were to build a light well outside here to serve light to the flats below.

“I don’t know if it was built or being built, but certainly the flames seen through the obscured glass of that little window were like looking into a furnace, as if the flames were in a chimney […] the kind of effect a light well might well create drawing the fire – and that against an ancient timber framed building, with a timber window looking into it from a hotel room and with no linked smoke alarm on the other side.

“In other words, potentially the fire transference would be simple and rapid as once a fire got into that light well there was no fire break and no warning system linked to the hotel.”

 

  1. Window of opportunity

From media reports it appears that there was a window of opportunity of between 1.5 and three hours when DSFRS thought that they had the fire in No 18 under control and this appears to concur with photographic evidence that shows very little fire at around 06.53 but fire spreading to the RCH at around 10.00 – so what went wrong?

A report on Devon Live said: “During that time the crews were damping down and removing roof tiles, and the aerial ladders were no longer in use. A multi agency meeting was called on Cathedral Green at 08.45 as all the emergency services thought the worst of the fire was over” – but clearly it wasn’t.

We are informed in the report that the fire “spread undetected through voids and other channels throughout the hotel leading to the sudden development of the fire.” This appears to refer to the various roof spaces and buildings on the roof line of the RCH, but many would have been clearly visible from an aerial ladder/surrounding buildings and thermal imaging should have shown any hotspots.

In addition to this if automatic fire detection had been installed in the various roof spaces the path of the fire could have been identified as it progressed through the building.

Another statement in the report that is confusing indicates: “While crews were still externally fighting the fire in number 18, additional fire crews were sent into the hotel building to search bedrooms for residents. During the search, crews reported that fire was breaking through from number 18 into the hotel.”

One of the crews searching the rooms in the hotel placed their hand against the adjoining wall of the bedroom which collapsed into number 18; the crews were faced with a wall of raging fire” – could this have been mistaken for the window in the compartment wall and adjoining ‘light well’?

Another confusing statement relates to roof access as the report states: “Access to the roof of the RCH was limited to the outside only with no access internally.”

I personally find this difficult to believe because internal access to roof spaces would normally be required for maintenance purposes. And while I accept that there may have been small spaces where access was difficult, generally there would have been some access to major roof voids.

  1. Conclusions

When I first looked at this fire it was clear that we needed three important questions answering and these were the cause of the fire, why the fire spread to adjacent buildings and what can be done to prevent similar occurrences, unfortunately this report does not address any of these points in sufficient detail to allow the reader to gain an informed insight into the fire.

There is very little information about the cause of the fire, what precautions were in place, what investigations and inspections were carried out both prior to the fire and during the investigation and I feel that this is a serious omission and simply to say everything was destroyed in not very helpful as this is generally the case in most major fires.

The question relating to fire spread from No 18 to the RCH is another one that has not been fully answered and simply referring to hidden voids that apparently DSFRS knew about before the fire is of very little help but what is important is what action was taken when these problems were previously identified and again there is no information provided on this.

Clearly, we all want to learn from this fire and DSFRS have stated that they are a “learning organisation” but they have provided very little information that the general public and fire engineering profession can learn from in respect of this incident. This fire has a large potential for us to learn about what really happened and to be able to gain valuable information about what went right and what went wrong.

One guest reported problems with a door that could not be opened whilst exiting the RCH building – was this investigated because he suggested it may have been a problem with the key card – did this fail safe?

Fire Risk Assessments are now an important part of the fire safety picture but they do not appear to feature very highly in this report and I think that the contents of fire risk assessments for No18 and the RCH should have been included.

In the recommendations section simply listing automatic fire detection and suppression systems without looking at basic fire compartmentation is not very helpful and the discrepancy in facts such as the time the incident was declared a major incident does not give the reader any confidence that some of the other statements are a true reflection of what really happened

BRE have published a study on Fire Comparmentation in Roof Voids that states “The fire protection of concealed spaces is of prime importance because any deficiencies in installation and materials are not readily apparent and may quickly be covered over. Any inadequacies in such fire protection cannot be observed by the building users and, unlike other engineering provisions within the building, will not be directly apparent by its impact on every-day life.

Any inadequacies in the fire protection of concealed spaces will only become apparent during the very time that their effectiveness is required – during a fire.”

The report also states “it also follows that the fire safety information required under Regulation 38 [9] is essential to those carrying out a fire risk assessment (under the Fire Safety Order) [10], so that the presence of concealed spaces can be identified and the fire protection they have been afforded can be assessed. It is important that this information is made available when required.

On a positive note it is good to see what looks like the “old Fire Certificate Plan” has been put to good use because it is quite surprising how many FRA’s tell me that these no longer exist.

As I have stated previously I think that this report does not provide an accurate picture of events before the fire because there are no submissions from other stakeholders involved including the HSE, Building Control, Insurers, Architects, Contractors, Historic England and witnesses. All of these people/organisations have an important role in this type of investigation and unless their contributions are included it is unlikely that we will benefit from this report.

We all need to learn the lessons from serious fires like this but unless the reports are open, honest and transparent I feel that we have lost another important opportunity to move forward and learn from these tragic incidents.

As I have stated previously, expecting any organisation that is responsible for the enforcement, fire fighting and investigation to meet these expectations is extremely unlikely and only a truly independent investigation is likely to give us a true picture of what really happened.

 

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tone
tone
March 19, 2018 4:01 pm

And i suppose you are the person to undertake these ‘independent’ investigations? I do agree that numerous issues do exist with this incident and within our industry in general but i cant see how a report like yours would help or reduce the risk to members of the public,staff,paying guests etc. Its so easy to pick fault and identify issues after events have happened but this is the real world and to be honest it looks like you would have just shut the business down or made it pretty much impossible to operate. It was a rare event that may… Read more »

John Grant
John Grant
March 19, 2018 6:21 pm

Pity they couldn’t second someone from RAIB (or AAIB) to show them how to do the job properly. I suspect the Grenfell inquiries will be no better.

Alan Cox
Alan Cox
March 22, 2018 12:38 pm
Reply to  tone

If you look at some of my previous articles you will see that when I have suggested that we have an “independent investigation” we have a team of specialists from different professions very much like the NFPA model see https://www.ifsecglobal.com/fire-service-right-enforcement-authority/ – I have never suggested anywhere that I would be the person to carry out these inspections. On your comment about my approach “would have just shut the business down or made it pretty much impossible to operate” I have worked in the fire and safety profession for over 50 years and never once have I suggested this and I… Read more »

Alan Cox
Alan Cox
March 22, 2018 12:50 pm
Reply to  John Grant

John, I don’t have a lot of experience of dealing with the Air or Rail Investigations Board but I am sure that there are things that we could all learn from them. I spent a lot of time working with the NFPA and FEMA in the USA and I learnt a lot from these organisations and one thing that really impressed me was how willing they were to share information and discuss different approaches that we have in the UK. I personally don’t think that we share enough information in the UK which is a great pity because even after… Read more »

Ian Malone
Ian Malone
March 30, 2018 9:34 am
Reply to  tone

Its to late when people are injured, but my take on the story is that we are still ignoring what we know and personally I would like the experts named . Who designed and fitted the systems ,who approved the work and insured it .Lessons can only learned if you have the facts.
While you say nobody died, budgets are kept and somewhere money was used for the fire and not elsewhere, tell the people at the local hospital not to worry.

Mike Kane
Mike Kane
April 4, 2018 4:48 pm

Interesting points raised here…..