Extreme Entertainment - New Zealand Fire Service

Transcription

Operational Review
Extreme Entertainment – 500 Ti Rakau Drive, Northpark, Manukau City
Incident Information:
F1192414
Structure Fire, 4th Alarm
0405hrs, 15th June 2012
Sponsor:
AC Larry Cocker, Area Manager Counties-Manukau Fire Area
New Zealand Fire Service, Region 1
Report completed by:
AAC Darryl Papesch, Assistant Area Manager Waikato
New Zealand Fire Service, Region 2
CONTENTS

Executive Summary
Page 3

Terms of reference
Page 4

Methodology
Page 6

Findings General
Page 7

Incident/building description
Page 7

Pre-incident events
Page 8

Planning/Incident information
Page 9

Discovery of Fire
Page 9

Fire service Response/Communications Centre
Page 9

Operational Instructions
Page 10

Water Supplies
Page 11

Command & Control
Page 11

Dynamic Risk Assessment
Page 12

HCU/eIAP
Page 12

Operations
Page 13

Safety & Wellbeing
Page 14

Hazards
Page 14

PPE Performance
Page 15

TOR Specific findings
Page 15
o
Review and investigate operations around BA function and
Page 15
Compliance with BA policy and Operational Instructions
o
Review and investigate the use of tactical communications (IGC)
Page 16

Liaison
Page 17

Debriefings
Page 17

Environmental
Page 17

Conclusion
Page 18

Sign off/Approval
Page 20

Appendix 1: SMS ICAD report
Page 21

Appendix 2: Aerial photo
Page 22

Appendix 3: Interior layout
Page 23

Appendix 3: ICAM – TOE Chart
Page 24

Appendix 5: ICAM – PEEPO Chart
Page 25

Appendix 6: ICAM – Why Chart
Page 26

Appendix 7: ICAM – Analysis Chart
Page 29

Appendix 8: Photos
Page 30

References
Page 39
Executive Summary
At 0450hrs on Friday 15th June 2012 the Northern Communications Centre dispatched appliances
to a Private Fire Alarm call at MA4 / 500 Ti Rakau Drive Northpark Auckland.
The PDA generated a 2 pump response, and the responding appliances were Howick 321 and Otara
331
On arrival; a K77 was transmitted. There was no sign of fire or smoke, but the fire alarm panel
indicated "fire”, zone 4". An external search was carried out on the building; and as no keys were
held by the Fire Service for access, a request for key holder attendance was made through FireCom.
After completing and external search, and with no signs of any fire showing or evident, the OIC of
HOW321 released the other attending appliance, and awaited the arrival of the key holder.
During this time HOW321 crew carried out periodic checks of the building, noticing during these
checks that access to the rear of the building was blocked by a locked security gate, and that there
were no windows available to view into the interior, other than the main ones where the crew was
located. (By the main entrance)
During one of these checks (Some twelve minutes after the other appliance had been stood down)
the officer noticed mural faces inside he could see previously now becoming obscured.
The OIC immediately ordered a forced entry through the window next to the main doors. At this
time fire behavior was observed to be light wispy smoke with a high neutral plane and unimpaired
visibility.
At 0522hrs; a second alarm was transmitted
Initial tactics were to make an offensive interior fire attack with the OIC and a crew member
entering the building wearing breathing apparatus and using a High Pressure Delivery (HPD).
Upon application of water the situation altered with the neutral plan dropping to the floor and
visibility reducing to near zero.
Subsequent operations included additional interior attack teams with High Pressure Hose reels and
an additional Low pressure delivery deployed.
During this time an incident of poor air management occurred, where a BA wearer did not have
enough air available to ensure a safe exit. Staff exited the hazard zone having run out of
available air.
The incident escalated to a 4th alarm and was successfully concluded at 1154hrs on 15th June
2012.
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Friday, 7 December 2012
Terms of Reference
1. An analysis of Communications Centre’s actions relating to the receipt of the call and
subsequent dispatches; the communication between the Communications centre and the
Incident ground

Service delivery Guidelines

PDA's

Appropriate appliance response
2. Analysis of the operational functions carried out during the incident;

resource allocation and function,

CIMS,

risk analysis

inter agency stakeholder relationships
3. Review of pre planning for fire at this risk or tactical plans and familiarisation of NZFS staff
on site.
4. Assessment of command and control systems in operation during the course of this fire, and
the Operational Procedures (Instructions) implemented.

Initial actions

Incident management structure

Effectiveness of strategies and tactics applied.
5. An analysis of the Fire Safety awareness of the occupants of the building and the status and
effectiveness of the evacuation scheme
6. Appropriateness and use of PPE
7. Assessment of fire ground safety procedures and procedures as required by policy
8. Review and incorporate findings of fire cause Investigation
9. The use, knowledge and adequacy of water supplies available in the immediate area.
10. Was appropriate liaison with other agencies established?
11. Consideration of the environmental impact of the products of combustion from the fire, and
the environmental impact arising from fire fighting operations. Analysis of the management
of Fire Service obligations under the Resource Management Act.
12. Provide any other information that may be of benefit for fire prevention, safety, operational
practices and the safety of others in the future
13. Post operational debriefs conducted, outcomes and corrective actions
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Sponsor specific TOR
1. Review and investigate operations around BA functions and compliance with BA Policy and
OI's
2. Review and investigate the use of tactical communications (IGC).
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Methodology/ Gathering of Evidence
On Friday the 28th June 2012, the Review team, consisting of, team leader AAC Darryl Papesch
(Region 2) and team members, AAC Jeff Maunder and AAC Des Irving (Operational Efficiency and
Readiness), SSO Craig Monrad (Region 1) and SO McSweeney (Region 2), conducted an operational
review into a 4th alarm structure fire that occurred at the Extreme Entertainment premises on
Botany Road, North Park, Auckland.
In addition to this was looking at the possibility for the need of a Level Two investigation for a
reported near miss incident involving a BA wearer becoming trapped in some of the machinery
inside the building and the end result of exiting the building having taken off their BA mask due to
running out of air.
The investigation included a visit to the site of the fire and interviews with Commanders and
Operational Staff involved in the incident.
Staff Interviewed:
IC and Member of IMT
: First arriving Officer and Member of IMT
: Operational crew
Operational Crew
Howick Volunteer Crew
The team then met to discuss the findings and produce operational review report.
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Findings General
General brief of findings
1. Breathing Apparatus - Air Management:
o Fire-fighters unable to exit within the requirements of the E3-2 Breathing Apparatus
Technical Manual.
o Policy compliance - Best practice guidelines of general responsibilities of BA Wearers
described in E3-2 TM Breathing apparatus & chemical protective clothing technical
manual Section 1 - Wearing Breathing Apparatus not adhered to.
2. Dynamic Risk Assessment: Not well done, changes in fire behaviour did not result in a
change in tactics, nor was there an appreciation of the increased & potential risk the
changes presented.
3. Fire Behaviour Recognition: Rapidly changing situation of wispy smoke to total loss of
visibility not acted on appropriately to the potential risk
4. Knowledge of appropriate flow rates – Poor recognition of the need to ensure adequate flow
rates when dealing with fires in large volume structures, and no considerations given to
potential escalation.
5. Tactical communications (IGC) - No identified issues were raised with fire ground
communication. It would always be advisable to formally set up and operate IGC tactically.
However it is also noted that currently there is no “mayday” or emergency action policy
around the use of tactical radios.
6. Safety Officer: Roles were not well understood or acted upon appropriately.
Incident/Building Description
The Extreme Entertainment building is a fire cell of 50m x 50m forming part of a larger building of
50m x 150m, timber frame and tilt slab construction with iron long run roofing, and plaster board
linings. Used as an indoor 10 pin bowling alley and games entertainment with a bar and restaurant
attached.
The plaster board lining that covered the
underside of the roof provided a fire
resistant protection that prevented the
ensuing fire from breaking through the
roofing iron and therefore contained the
fire to a "compartment” type fire. The
determined tactics were an offensive
interior fire attack.
The tactics deployed were a HPD
interior offensive attack backed up
with one low pressure delivery. The fire
was contained to the area of origin. Due to the large volume of the building and heavy smoke
logging it took a few hours to ventilate to a point of providing clear visibility for salvage and fire
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investigation cause to be initiated. Aerial appliances were utilised for roof access where iron was
removed to speed up the ventilation process.
Command and control was established and effective, with sectorisation and IMT deployment
supported by the Auckland City Hazmat/Command Unit (HCU).
Adjoining shops were unable to open for some time during the following operations but were
back and running at approximately 1300hrs.
The event was closed (Fire Service appliances no longer in attendance) at 1154hrs.
Pre Incident Events
The building history in SMS reports two fire related incidents in the last 3 years, one being an outside
rubbish skip bin at the rear of the building on fire and smoke from air-con ducting being the second
incident. Also recorded against another address point although for the same premises were three
false alarms, one being defective, one accidental and the last, undetermined .
The premise has an approved evacuation scheme and has conducted regular trial evacuations.
1
Evacuation Scheme Monitoring
1.1 Our Expectations
If the building was required to have an maintain an evacuation scheme by legislation, then it would
be compliant
1.2 Our Findings
We found that the premises did have an evacuation scheme that had been approved in June 2005
under 500 Ti Rakau Dr. The last recorded Trial Evacuation was conducted on the 26th Sept 2011, 9
months prior to the incident. In addition under a different address point 500 Ti Rakau Building B
shops 1 and 2 was a further approved evacuation scheme.
It is apparent that information has been recorded on alternative address points with no link
between the two that would give clarification. Trial evacuations have been recorded against the
other buildings and no record of a trial evacuation is recorded against the address containing the
approved scheme in Feb 2010.
Opportunity for Improvement 1: Ensure that the systems in place continuously identify and advise
premises requiring evacuation scheme compliance of their obligations’ under the act and ensure that
the New Zealand Fire Service meets its own requirements in this area.
Opportunity for Improvement2: Ensure that address points for buildings recorded SMS are accurate
and if there are multiple points are linked and or the information in the history etc is duplicated
across the listings.
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Planning/ Incident information
The building has a risk score of 10 and no site plan/report exists (Assessed March 2005)
2
Operational Planning – Site/Tactical Plans
That the building would have been risk assessed and based on that risk assessment the requirement
for a site report would have been determined.
2.2 Our Findings
We found that the building risk assessment was out of date and subjectively a bit on the low side,
however the premises would not have met the threshold for a high risk building (Currently set in
SMS as a Risk score of 16+). As such it would not be expected to have a site report.
Discovery of Fire
Fire Service Response/Communications Centre
3
Call receipt and dispatch
The communications centre would meet the Service delivery guidelines in relation to call receipt and
dispatch
3.2 Our Findings
We found service delivery guidelines for calls within urban fire districts (ComCen processing times)
of 1min 30 sec were met (0 min 18 sec)
4
Response
That responding appliances (career) would meet the Service delivery guidelines in relation to call
receipt and dispatch
4.2 Our Findings
We found service delivery guidelines for calls within urban fire districts (1st appliance) of 8 minutes
were met (6min 01 sec)
NZFS Department of Operations and Training, N7a Schedule of service delivery guidelines, Page 1
(December 2010)
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Operational Instructions
5
Compliance with Policy and Operational Instructions
All policy and Operational instruction requirements would be complied with.
5.2 Our Findings
Policies /OI’s reviewed were; IS1 Safety, M1 Command & Control, OS5 OSM, BA (ref)
Issues identified around non compliance are:
E-3.2 Breathing apparatus TM
A: Air management: Failure to exit with appropriate air reserves remaining in line with compliance
guidelines found in E3.2 BA TM (Exits as warning whistle begins to sound – 10 min reserve)
B: Failure to maintain team integrity, resulted in FF becoming separated and subsequently
entrapped (However minor). This also led to an increased consumption of air, resulting in an early
activation of the warning whistle.
This was then seen by other crew members as a possible set fault and investigating this, further
delayed the FF’s exit from the building.
M1 POP Command & Control TM
C: Command & Control: Dynamic risk assessment (ref M1 POP): Dynamic risk assessment appears to
have been poorly utilised, in that: one entry had been made and a significant fire discovered, the
decision to continue to attack the fire in an aggressive internal mode with a HPD and no supporting
appliances appears not to have considered the worst case scenario.
In addition the change in fire behaviour changes was not factored into the tactic deployed, placing
the crews at risk.
The OIC’s decision to continue firefighting operations after initial entry and fire escalation is a
significant contributing factor to the above, due to a lack of available resources and the conflict
between command and control functions verses the BA team requirements.
IS1: Incident ground safety: Safety officer deployments did not align with role and responsibilities (OI
– IS1 page 4)
Opportunity for Improvement 3: Ensure that all staff are aware and understand the requirements to
comply with the air management requirements in E3-2 BA TM
Opportunity for Improvement 4: Ensure that all staff are aware and understand the requirements to
comply with working in BA teams as required in E3-2 BA TM
Opportunity for Improvement 5: Ensure that all officers are aware and understand the requirements
of dynamic risk as assessment as per the M1 POP TM (Command & Control)
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Opportunity for Improvement 6: Ensure that all staff are aware and understand the roles and
responsibilities of the safety officer and the protocols around the appointing of said safety officer (IS1
Incident safety)
Water Supplies
6
Knowledge and use of water supplies
The expectation that the locations and flow rates of water supplies would be known to crews and
that documented intelligence around the capacity and flow rates of the mains would be available to
the IMT
6.2 Our Findings
Water supplies that were located and used were appropriate and supply was ample for the tactics
used.
No data was available from the HCU in regards to documented capacity, flow rates and currency of
water testing in the area.
Opportunity for Improvement 7: Water supply information should be available to all HCU’s
regardless of where they are located.
Command & Control
7
Structure/ M1 POP Compliance
The team expected to see command structure and IMT established as per the M1 Command &
Control TM, for an incident of this magnitude.
That the command and control structure provide clear lines of communication and was a major
contributor to the successful conclusion of the event
7.2 Our Findings
A command structure was established with IMT and sector functions deployed in line with policy.
This structure included; Incident Commander, Operations Commander, Planning & Intel
Commander, Safety Officer, Logistics Commander and 2 Sector Commanders.
The command structure was effective and did lead to an effective extinguishment and containment
of the incident.
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Staging of greater alarm assets, (Including Commanders) staging needs to be initiated as early as
practical, to ensure that all responding staff report to and are controlled by IMT.
Commanders who are not in the IMT and not assigned roles should not be freelancing in the incident
ground (Hazard Zone) as this led to confusing and conflicting task assignments for operational crews.
Additionally the wearing of non appropriate PPE and role identification further added to confusion
when these commanders were on the fire ground
Opportunity for Improvement 8: All personnel responding to greater alarms must comply with policy
(M1 POP TM)and report through staging or through ICP and await to be assigned a role and position
within the chain of command by IMT, before entering and operating on the Incident Ground.
Opportunity for Improvement 9: All personnel responding to Incident grounds must wear the
appropriate PPE for their assigned role.
8
Dynamic Risk Assessment
We expected that all Officers would understand and comply with the requirements for conducting a
dynamic risk assessment as per the Command & Control TM (POP M 1 TM) & The Safe Person
Concept.
8.2 Our Findings
We found that due to the nature and size of the building, that inappropriate consideration was given
to the risk presented by the use of less than appropriate water flows for interior fire attack (ref).
Once entry had been made, and water applied, the change in fire behaviour and the risk to
personnel was not recognised and no appropriate action taken to mitigate it.
Opportunity for Improvement 10: Ensure that operational Officers are aware of the current
acceptable flow rates for entry into structure fires and apply this knowledge operationally
Opportunity for Improvement 11: Ensure that current staff training around fire behaviour is current
and is continuously revisited.
9
HCU operations/eIAP
We expect the HCU to provide excellent command support to commanders, with crews having indepth knowledge of systems including the Electronic Incident Action Plan (eIAP)
9.2 Our Findings
The HCU was established and set up at 0552hrs within 30 minutes of being dispatched from
Auckland City and approximately one hour from the initial turn out. Note: Otara's HCU was not on
station as it was in attendance at another incident.
The operators had set up the eIAP but limited information was entered or recorded.
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The HCU Officer chose to limit the information recorded at this incident as he believed the incident
did not warrant it.
Opportunity for Improvement 12: Develop a protocol around the saving of eIAP sessions so that the
whole history of the incidents command structures and appliance positioning can be maintained, this
will prove especially useful for operational reviews and debriefs.(Note this protocol should be
considered at a national level)
Opportunity for Improvement 13: Develop an operational instruction outlining, protocols around
manning of the HCU and requirements to set up eIAP. This should include the requirements to ensure
that the eIAP can give an overall and complete picture of the incident as it develops through to
completion.
Operations
10 General Fire fighting operations
We expected a high level of operational competence across all areas of operations.
9.2 Our Findings
Aside from the issues mentioned in this report, other fire fighting operations were deemed to have
been conducted well, with effective use of water supplies, aerial appliances, appliances, staff and
support assets.
This combined with an effective incident action plan, meant that the incident was concluded
successfully.
11 Water flow rates for structure fires
We expected a high level of operational competence to be demonstrated through appropriate
tactical choice of firefighting medium based on the planning backward principle of worse case
scenario occurring.
9.2 Our Findings
Current international data, as well as training programmes within the NZFS, advocate that crews
carry adequate water (Flow rates) to ensure that they are able to safely egress from an incident
should the fire behaviour escalate beyond what is currently showing.
The use of Hpd’s in this large volume structure; especially after a significant change in fire behaviour;
as evidenced in this incident, is a serious concern. It presents a considerable risk to staff given that
lack of available flows (4.0l/s) from this type of delivery will not provide this level of protection.
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It is important that Officers make their decisions on the type of delivery used, based on the worst
case scenario for a given structure, and that flow rates are a major consideration over the ease of
use or speed of deployment.
Opportunity for Improvement 14: Publish as part of a training programme the current minimum
flow rates for structure fires.
Opportunity for Improvement 15: Develop training and assessment procedure that ensures that
officers are aware of the requirements around the minimum water flows for entry into structure fires
Safety and Wellbeing
12 Compliance with IS1 Operational Safety
We expected to see compliance with IS1 and our requirements under the Health and Safety act
1992, section 13 & 19, especially around the appointment of safety officers and hazard identification
12.2 Our Findings
We found that while a Safety officer was appointed as per policy, evidence suggests the role did not
function as intended, as an incident hazard management plan was not developed nor implemented.
Additionally the safety officer was involved in directing staff in operational roles.
Opportunity for Improvement 16: Ensure that staff training ensures that appropriate staff are
appointed to the safety officer role and that the individual appointed knows and understand the
requirements for the role.(OI – IS1)
Hazards
13 Hazard Identification and Advisories
We expected to find that all Hazards identified on the fire ground were recorded in the eIAP and that
all staff operating on the fire ground would be advised.
13.2 Our Findings
There is no evidence of an incident hazard plan being developed, nor is there any evidence of any
identified hazards being entered into eIAP.
Opportunity for Improvement 17: Ensure that all identified hazards are recorded in the Incident
Hazard plan recorded in eIAP and is part of any incident ground tactical broadcasts.
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PPE performance
14 PPE
We expected to find that PPE performed to the expected level and that if any issues were identified
they would be reported.
12.2 Our Findings
No issues were reported concerning PPE.
Findings (in relation to TOR)
Specific issues related to TOR not identified in the main body.
Breathing Apparatus
15 Air Management
15.1 Our expectations
The review team that operational crews would conduct their operations in accordance with the E3-2
TM Breathing apparatus & chemical protective clothing technical manual
15.2 Our findings
The review team found that in a specific case a FF was unable to exit within the requirements of the
E3-2 Breathing Apparatus Technical Manual.
A firefighter ran out of air and was forced to remove his mask before he had safely exited the
structure and while still in an irrespirable atmosphere.
The contributing factors are reviewed below;
Crew Separation: FF and OIC were the first crew, they became separated as their roles became
divergent, the OIC Resumed his command role and the FF continued with F-Fighting (alone).
Even though another FF was tasked with joining up with the original FF, this is in contradiction to BA
policy regarding working in teams. (Breathing Apparatus Technical Manual, NZFS Training, May
2011, Sec 2, Pg4)
This was further exacerbated by the FF (alone) becoming entangled and using up a significant
amount of air in extracting himself.
Entrapment: The factors that enabled the entanglement to occur included that the FF was alone and
continued firefighting in an unfamiliar area. He also was attempting to access the fire through a
confined space in which he became lightly entangled.
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During this time of entanglement; his anxiety levels had risen to a point where he has used a
significant amount of his available air; he now had considerably less duration remaining than his
companions.
During this entanglement period, the FF did not activate his DSU, nor did he request assistance via
his tactical (IGC) radio.
As he was making his way to exit, with his whistle sounding, it was thought the FF had a set fault and
the FF was further delayed as other staff sought to investigate the fault.
Opportunity for Improvement 18: Determine why the requirements of E3-2 were not complied with
in regards to BA team dynamics and identify remedial action where necessary.
Opportunity for Improvement 19: Ensure greater emphasis placed on individuals to set off their DSU
and request help via a tactical radio as soon as any entrapment occurs
Opportunity for Improvement 20: Emphasis the need to manage air and to take early actions to
prevent air exhaustion. Reinforce the requirements of E3-2 BA tm.
16 BA Procedures
The Review Team expected to find a controlled system in place with BACO and entry control points
coordinating their resources and monitoring operations.
16.2 Our findings
The Review Team found BACO and Entry Control points operated efficiently and without incident,
identifying and recalling BA wearers prior to time due out.
Tactical Communications (IGC)
17 Review and investigate the use of Tactical communications (IGC)
The Review Team expected to find that an effective communication plan would have been
developed and employed as per Command & Control Policy requirements, (M1 POP) and that this
plan would have contributed to the effective conclusion of the incident.
Additionally we expected to find a robust and promulgated tactical radio procedure that includes an
“emergency” (Mayday) procedure.
17.2 Our findings
The Review Team found that an effective communications plan was implemented in compliance
with policy and contributed as expected.
We also found that there is not a laid down emergency procedure for tactical radios, and that in
general tactical radio use is very casual and uncontrolled. This impedes the effectiveness of tactical
radios for use in emergency situations, and reduces the confidence staff have in using them when
requesting assistance.
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With the advent of BA comms this problem of uncontrolled use, will be exacerbated as the radio
traffic will be increased considerably.
Opportunity for Improvement 21: There is not any formal Tactical radio policy and use procedure in
place including an effective and consistent emergency (mayday) procedure in place.
A tactical radio strategy and operating protocol must be developed that includes the use of tactical
radios during emergency situations. (Mayday procedure)
Liaison
18 Stakeholder liaison
The Review Team expected to find that effective stakeholder liaison had been established and
maintained during and post incident.
18.2 Our findings
The Review Team found that effective stakeholder liaison had been established and maintained
throughout all aspects of the incident.
Effective liaison was established with all the stakeholders, including the Business and property
owner, and neighbouring business owner and this liaison affected their return to their premises in an
informed and timely manner.
Debriefings
19 Incident debrief
The Review Team expected to find that a formal debrief for this incident had been conducted.
19.2 Our findings
The Review Team found that an informal debrief did take place, conducted by AAC Clarkson with the
initial crews/Officers in attendance. One OFI was identified, as below.
Opportunity for Improvement 22: Ensure that BA helmet markings are applied to all staff, to aid in
the identification of suitable BA wearers. (Especially with volunteer staff)
Environmental Impact
20 Obligations - Resource Management Act (RMA)
The Review Team expected to find that the NZFS had met all its obligations under the RMA.
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20.2 Our findings
The Review Team found that NZFS complied with the requirements of the RMA although the below
text should be considered carefully.
There is no evidence of an environmental impact assessment being recorded that recognises the
potential impact of firefighting operations on the local environment.
“The Fire Service is generally required to act in situations where there is a fire emergency and is
empowered to act in the case of other emergencies. In order to effectively carry out its functions and
duties, the Chief Fire Officer of the district has powers under s28(3) and (3A) of the Fire Service Act to
take whatever action is necessary to save lives and property in danger. It is arguable whether powers
properly exercised by the Fire Service when dealing with emergencies are exempt from the RMA.”
(http://www.qp.org.nz/rma-enforcement/emergency-powers/index.php#epfsa1975)
Opportunity for Improvement 22: Commanders and Officers should ensure that they are aware of
the responsibilities of the NZFS in regards to environmental impact during firefighting operations.
Conclusion:
The incident at Extreme Entertainment has identified a number of areas that should be considered
of significant concern.
While the incident itself was extinguished and contained well, the areas of concern that have been
identified within this report must be addressed both locally and at a national level.
Breathing apparatus procedures and skills appear to be significantly below expectations and it only
shear chance that this incident did not have a fatal outcome for one of our fire-fighters. To have fire
fighters run out of air at an incident indicates a systemic failure of compliance with Operational
Instruction E 3-2 as well as considerable deviation from training given by the training department.
This poor performance across, air management, crew management, use of DSU’s, Tactical radios and
a general non compliance with the BA Technical manual places both the organisation and our staff at
considerable risk.
In addition the poor understanding of the risks and potential risks around the poor selection of
deliveries and water flows, and subsequent inabilities to adjust tactical solutions based on a dynamic
risk assessment of a changing fire environment and fire behaviour again pose a considerable risk.
In addition it must be noted that the OIC’s decision to conduct offensive interior operations without
other appliances and crews available led to the situation with BA team separation due to the
diverging roles within the team, as the OIC moved to a command function, while the Firefighter
remained focused on firefighting operations. The subsequent separation and entanglement of a
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firefighter working alone in the hazard zone in direct violation of policy and protocols and could
easily have led to a more serious outcome, given his air exhaustion upon exit.
While in this case the organisation escaped without any damage both to our reputation and our
staff, this trend of non compliance and underestimation is not limited to this one incident.
Significant international research is showing that as the number of fire related incidents decrease
and our operational staff take up a wider range of roles, the risk of injury and death increases
significantly as their actual live firefighting experience decreases. (Paul Grimwood, FireTactics.com,
2007)
It is also an opportune moment to review our tactical radio procedures and ensure that the NZFS
develop effective protocols around communications plans, mayday procedures and embed
professional and formal tactical radio procedures, rather than the chatter channel use they have at
the moment.
Extreme entertainment was an example of a fire that didn’t make the news and was successfully
extinguished.
However there are too many incidences of potentially disastrous events that should the worst have
happened, the consequences would be severe.
We must accept that this is a developing trend and conduct research to determine way and
development methods to mitigate further risks to the organisation and our operational staff.
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Report Approval
Investigation and report completed by:
Investigator
Name: Darryl Papesch
Rank: Assistant Area Commander
Role: Assistant Area Manager, Waikato
Everything in this statement is true to the best of my knowledge and belief, and I made the statement
knowing that it might be admitted as evidence for the purposes of the standard committal or at a
committal hearing and that I could be prosecuted for perjury if the statement is known by me to be
false and is intended by me to mislead.
Signed: …………………………………………..
12 November 2012
Date: …………………………………………..
The report has been peer reviewed by:
Name: Jeff Maunder
Rank: Assistant Area Commander
Role: Manager Operational Efficiency and Readiness
Signed: …………………………………………..
12 November 2012
Date: …………………………………………..
This report has been approved by:
Name: Larry Cocker
Rank: Area Commander
Role: Area Manager Counties Manukau (Area 5)
Signed: …………………………………………..
27 November 2012
Date: …………………………………………..
This report complies with the New Zealand Fire Service Official Information Policy (POLCM.2.)
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Appendix 1: SMS ICAD Report
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Appendix 2: Aerial View – Appliance disposition
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Appendix 3: Interior Layout
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Appendix 4: ICAM – Time Ordered Events
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Appendix 5: ICAM – PEEPO
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Appendix 6: ICAM - 5 Whys
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Appendix 7: ICAM – Analysis
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Appendix 8: Photos
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References:
New Zealand Fire Service Operational Instructions (http://firenet.fire.org.nz/OperationalInstructions/Pages/default.aspx)
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NZFS Department of Operations and Training, N2 TM NZFS Uniform and PPE manual
(December 2011)
M3 - Communication protocols – operations
M1 TM - Command and Control Technical Manual.
RD 2 Operational Planning
M1
Command and Control
M2
Mobilisation
G1-1 Nominal Roll Tally
G5
Protection of the environment
N2
NZFS Uniform and PPE manual
IS1
Operational Safety
P2
Operations Reviews
FL4
Aerial Appliances
OS5
Operational Skills Maintenance
Quality Planning Website – RMA Resource: (http://www.qp.org.nz/rma-enforcement/emergencypowers/index.php#epfsa1975)
ICAM Advanced Investigation Techniques – Impac 2012
mPad File number: OR-2012-000016
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Extreme Entertainment - New Zealand Fire Service

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