resulting in the death of - institution of fire engineers

Investigation Into Incident Number 10644

RTC A1(M)

Resulting in the death of

Sub Officer Paul Mallaghan

and injuries to

Leading Firefighter

16 June 2007

Hertfordshire Fire and Rescue Service

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Contents1. Executive Summary

2. Sequence of Events

3. Operational Procedures

4. Clothing, Equipment, Vehicles andCommunications

5. Training and Competence

6. Findings

7. Recommendations

8. Bibliography

9. AppendicesAppendix 1 Plan drawings showing stages of vehicle positions Appendix 2 Glossary of Fire Service termsAppendix 3 Appliances and crews attending the incidentAppendix 4 Sequential Timed Event Plotting Information

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Introduction

This is an investigation report into incident number 10644 on Saturday, June16, 2007 attended by Blue Watch Stevenage. Whilst dealing with this incidentSub Officer Mallaghan was fatally injured, Leading Firefighter sustained head and leg injuries and a Highways Agency Traffic Officersustained a fractured leg.

Background

On June 16 2007, just after 09.15 pm, Fire Control received a call to a car firebetween junctions 8 and 7 on the A1(M). Two pumps from Stevenage FireStation were mobilised. The car on fire was a burgundy coloured Saabregistration number

It was during this incident, just after the car fire had been extinguished, a redVolkswagen Golf hatchback, registration number travellingsouthbound left the main A1(M) carriageway and hit the rear of the Saab. LFf

was standing to the front near-side (next to the wing mirror) of theSaab and SubO Mallaghan was standing at the front of the Saab looking underthe bonnet. The Saab was shunted approx 15m along the hard shoulder fromits original position, throwing LFf into a Highways Agency Traffic Officerand trapping SubO Mallaghan underneath the front of the Saab.

The photographs (fig 1 and 2) on the next page show the scene immediatelyprior to the collision and were taken by an off-duty Police Officer.

The exact time the photographs were taken is not known, however, fireappliance 231 does not appear in the photograph because it had already leftthe incident at 21.29.01 due to the arrival of the Highways Agency vehicle –which can be seen parked behind the Saab. Two Highways Agency TrafficOfficers also appear to be standing next to the Saab.

It was after this point in time that the VW Golf collided with the Saab justbefore the subsequent ‘priority message’ was sent to Fire Control at 21.35.24by Ff

A detailed narrative sequence of events is included in Section 2 of this reporttogether with the tabulated Sequential Timed Event Plotting (STEP)Information at Appendix 4.

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Hertfordshire Fire and Rescue Service RTC A1(M) Investigation Report

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Police Investigation

Hertfordshire Constabulary attended the scene post collision to manage theroad traffic incident and immediately commenced a Crash Investigation.Hertfordshire Fire and Rescue Service (HFRS) have cooperated with thePolice throughout their investigation, providing information on HFRS safesystems of work and operational procedures. Three firefighters fromStevenage were interviewed as witnesses by the Police to assist them in theirinvestigation.

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Fig 1scene prior tothe collision

Fig 2scene prior tothe collision

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On the night of Saturday 23 June 2007 the police undertook a reconstructionof the scene and event with the cooperation of HFRS and the HighwaysAgency. HFRS provided the same fire appliance with another Service driver,and the Highways Agency provided their vehicle to enable the reconstructionto be as accurate as possible. Divisional Officer attended thisreconstruction and this enabled him to take some video footage.

The police were unable to share the outcome of their Crash Investigation atthe time this accident investigation was produced. The identity of the driversof the vehicles is therefore unknown in addition to any scientificmeasurements made by the police at the scene and subsequent technicalcalculations following the reconstruction. The Saab driver’s account is alsonot known.

Accident Investigation

At 22.24 on the night of the 16 June 2007 StnO was alerted byCommand and Control and instructed to attend incident 10644 in order tocarry out the initial accident investigation and gather evidence on behalf ofHFRS. StnO liaised on scene with StnO and DivisionalOfficer who had been mobilised to the incident and briefed him. Healso liaised with Police Constable the officer carrying out the CrashInvestigation. StnO took photographs of the scene post-collision.He has subsequently confirmed that in order to draw a picture of the scene hewas able to pace the distance between the positions of the vehicles in a fairlyaccurate manner utilising the markings put in position by the police officerduring his investigation.

On 17 June 2007 the Health and Safety Executive was informed of the incident.However the HSE Inspector for the area explained that the HSE does notregard such an incident to be reportable because it is a road traffic accidentand as such is not considered by the HSE to be an injury at work.

The Strategic Leadership Group (SLG) made a decision to undertake aninternal Accident Investigation and this was led by ACO who appointedDivisional Officer and Health and Safety Manager tocarry this out.

This process involved a tested method of ascertaining the sequence of eventsin detail using the following sources of information:

1. Contemporaneous notes of those firefighters who attended theincident, (Stevenage, Hitchin, Baldock & Letchworth and the Hatfield Rescue Support Unit – see Appendix 3).

2. Contemporaneous notes of the officers who attended the incident.

3. HFRS Command and Control Log.

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4. Taped recordings of telephone calls and radio messages to Command and Control.

5. Highways Agency Control Log.

6. The Highways Agency Traffic Officers account of the incident.

7. The Highways Agency ‘Hot Debrief’.

Once the facts of the event were established an analysis of the circumstancesinvolved a review of these main areas:

HFRS operating procedures for working on roads compared to the national arrangements (e.g. Generic Risk Assessment and Fire ServiceManuals) and the operating procedures used by the Highways Agency andPolice Service.

Statutory and legal requirements relating to working on roads to ensureHFRS complies with the safety standards for working on roads, includingconspicuity of personal protective equipment and vehicles.

The use and availability of operational equipment and personnel, plus theeffectiveness of communications.

These will be covered in separate sections in the report.

The list of reference documents and bibliography can be found at the end ofthis report.

There are some discrepancies and inconsistencies which exist in both theHighways Agency Officers and firefighters assessments of the distances thatvehicles were originally parked and subsequently ended up. Without thedetails and technical calculations from the Police Crash Investigation it isimpossible to be accurate with any certainty. The distances quoted byindividuals therefore need to be considered as their perceptive estimates.The distances quoted by StnO are possibly the most accurateavailable to the Investigation.

Fire Brigades Union

The HFRS Accident Investigation officers met regularly with the FireBrigades’ Union to ensure they were kept fully involved and updated on theprogress of the internal investigation.

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Statistics

The Highways Agency national statistics reveal that in the last 18 monthsthere have been 12 incidents involving Highways Agency Traffic Officersworking on roads across the country, but to date no fatalities. However, for afive year period from 2000-2004 accidents on the hard shoulder claimed thelives of 67 people and a total of 950 people were injured.

Although there have been no reported fatalities involving UK Fire Servicepersonnel whilst working on roadways, on 25 February 2007 in Eire afirefighter from Limerick County Fire Service and a Garda (National policeofficer) were killed by a speeding motorist whilst dealing with an road trafficcollision (RTC).

Safe Operational Procedures

Not withstanding the recommendations made in this report, and the safeoperating procedures adopted by all those attending this incident, noreasonable additional precautions could have guaranteed the safety ofindividuals working on the hard-shoulder of the motorway.

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2 Sequence of EventsA detailed sequence of the events has been gathered from the followingevidence:

Contemporaneous notes of individual firefighters and officers whoattended the incident, (a list of crews and appliances attending canbe found at Appendix 3),

HFRS Command and Control Log,

Taped voice recordings of telephone calls and radio messages toHFRS Command and Control during this incident,

Highways Agency Control Log,

Highways Agency Hot Debrief,

Highways Agency Traffic Officers’ notes.

The sequence of activities and individual tasks are estimated within the giventime parameters. Any distances or measurements given by individuals in theircontemporaneous notes are quoted as stated and may not necessarily beaccurate or correspond with others.

Significant events are in blue bold type; informative messages and otherimportant information are in black bold type. Quotation marks have been usedto indicate individuals’ words taken from their contemporaneous notes.

Fig 3 is a photograph of the A1 motorway junction 8 to 7 southbound in daylightshowing the slip road merging with the main carriageway on the right of thepicture.

Fig 3View of A1(M)

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This stretch of the motorway was not lit and at the time of the incident it wasdusk. There are no closed circuit television cameras present at this junction.

The sequence of events below is provided in the presenttense as the event occurs.

(A glossary of fire service terms can be found at Appendix 2).

At 21.16.36 on Saturday 16 June 2007 Command and Control receive a 999 callfrom a mobile phone reporting a car on fire on the hard shoulder of the A1(M)at junction 8 to 7 southbound.

Stevenage appliances 230 and 231 are alerted at 21.17.44/53 respectively. The Highways Agency is also fully aware of the incident at 21.19.22 - informedby the police.

231 booked mobile at 21.20.02 to the northbound unaffected carriageway withLFf as the officer in charge and a crew of four: Ff - driver,Ff and Ff

230 booked mobile at 21.20.24 to the affected carriageway southbound withSub Officer Mallaghan in charge and a crew of four: Ff driving, LFf

and Ff

As 231 approach from the northbound carriageway of the A1(M) LFf confirms that there are two cars just on the motorway southbound and radiosto SubO Mallaghan in 230, now approaching on the slip road, that it is thenearest car to them – the burgundy Saab - which is the one on fire.

230 are at this time on the slip road travelling south to join the A1(M) and Ff the driver, sees a second car with “hazards and people”, and smoke

coming from the bonnet of the first car – the burgundy Saab. (Firefighterssubsequently recall the second car as possibly being a silver Nissan Micra.)

230 books in attendance at 21.24.58.

Ff states that when LFf radioed 230 was too close forthem to pull in behind the vehicle on fire so Ff parks the appliance infront of the Saab “6 lengths” – Ff estimates 15 metres away from thefront of the Saab. The blue lights are on.

When parked LFf says he can see the Saab has a small fire under thebonnet and it is mainly steam plus oil dripping from the bottom.

Ff gets his fire kit off and wears his high visibility jacket because“traffic is heavy.” He stands at the pump.

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Ff takes off a BA set from the nearside of the fire appliance whilst LFf and SubO Mallaghan proceed to the vehicle on fire. Ff runs the

hose reel out from the nearside and takes it to the vehicle. By the time hereaches the fire car 231 have arrived.

231 books in attendance at 21.25.47. The appliance parks in the 'fend off'position (at approximately a 45 degree angle) across the slip road and hardshoulder behind the Saab. LFf radios SubO Mallaghan to ask if heneeds assistance. SubO Mallaghan replies “no.” The crew remain on theappliance.

SubO Mallaghan is wearing his helmet and also the OIC surcoat over his firetunic.

LFf says that SubO Mallaghan is talking to the vehicle owner whilst LFf opened the bonnet of the car for Ff to put the hose reel on the

minor fire. Ff is not under air and extinguishes the fire fairly quickly.

LFf sees the Highways Agency vehicle approaching on thenorthbound carriageway. SubO Mallaghan then radios LFf that “theHighways Agency is here, you might as well get yourself away and they canmove into your position.” In the appliance off-side mirror Ff also seesthe Highways Agency vehicle coming up the slip of junction 8 southbound.

LFf asks SubO Mallaghan if he wants him to get the details for the FDR1and LFf walks to the appliance (230) where the owner is stood. LFf removes his helmet and gloves to talk and write the information down. It iswhilst LFf is talking to the owner that SubO Mallaghan radios LFf

on 231 and tells him to go.

At 21.28.58 the Highways Agency (HA) vehicle arrives and books in attendancewith their Control. They are a crew of two Traffic Officers – one female , onemale ( They park behind the Saab some distance away, in their ‘fend offposition’ suitable for the incident (i.e. in line).

The photograph overleaf (fig 4) was taken post-collision during the accidentinvestigation showing the exact position of the Highways Agency vehicle whichhad not been moved since its arrival. (In the background are cars parked by theoncoming fire officers).

231 books mobile return at 21.29.01 and leaves the incident down the A1towards junction 7.

Ff asks SubO Mallaghan if cones are wanted and SubO Mallaghantells FF that the Highways Agency will do that. Ff is thenstanding at the rear of the pump acting as Safety Officer.

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The Highways Agency officers exit their vehicle and goes to the rear of theHA vehicle and Highways Agency Traffic Officer speaks to SubO Mallaghanand states they will get the car moved when it is cool.

LFf walks with the owner to the rear of the Saab where the HighwaysAgency officers are standing and introduces the owner to Highways Officer

and the owner of the Saab now stand behind the barrier on the hardshoulder to discuss recovery of the vehicle. The Highways Officer approaches the ‘scene’/Saab because he feels that the vehicle needsimmediate removal due to the location being unlit. He tells this and sheradios HA Control to ask them to arrange this (21.30).

21.30.23 Ff sends an informative message to Control from 230“SubO Mallaghan, small fire in engine compartment, 1 BA 1 hose reel in use,Tactical Mode Oscar.”

After checking the engine Ff asks SubO Mallaghan if it’s OK toremove his Breathing Apparatus and return to 230. Ff re-stows hisBreathing Apparatus set in the rear of the appliance, which is a spareappliance (provided because Stevenage’s main appliance (230) was beingserviced).

Ff is preparing to send a STOP message from the OIC seat.

LFf walks back towards 230 and SubO Mallaghan is now standing at thefront of the Saab looking at the damage. Ff says SubO Mallaghan pointsto the engine block and says “it’s something down there.” LFf movestowards the front of the Saab to talk and look at what SubO Mallaghan is doing.LFf is standing next to the near-side wing mirror and the otherHighways Agency Officer ( is standing next to LFf

LFf hears a sudden bang and massive noise and he sees“blackness/light/black/light/black/light.” It goes all quiet and he is now laying

Fig 4Position ofHighwaysAgencyVehicle onhardshoulder (fireservice carsparked torear postcollision)

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in the road feeling confused with fluid/blood running down his face. He moveshis left arm and felt a curb and moved himself half on that for safety. He is alsolying on top of the fire hose.

Ff hears a noise whilst he is in the cab and looks in the mirror. Ffis getting kit together when he hears “a quiet bang” and says to Ff “what was that?” He is aware that something went past the

appliance.

LFf sees Ff and Ff get off 230.

Ff sees a firefighter laying on the hard shoulder some distance awaywhere the “fire vehicle” originally was and a different car on the motorway.

The male Highways Traffic Officer has been knocked over the barrier by LFf being thrown into him.

Ff goes over to LFf speaks to him and confirms he is OK andthen scans the scene looking for SubO Mallaghan. Ff says he didn’trealise the initial fire vehicle (the Saab) was now right behind 230 but then hesees a new vehicle is involved (a red hatchback Volkswagen Golf), heavilydamaged and facing the wrong way up the motorway. On getting closer to theSaab he sees SubO Mallaghan and assesses his condition.

Ff initially sees that the Saab had been shunted into lane one, LFf is laying on the hard shoulder and Ff goes over to him. SubO

Mallaghan is under the Saab and Ff goes over to SubO Mallaghan, buthe isn’t responding and “he is obviously in a bad way.”

At 21.35.24 Ff returns to the appliance and sends a priority message“Collision on A1 Make pumps 2 ambulances required RTC involving appliance,persons trapped.”

The crew of 231 hear this priority message and they mobilise back to the A1.

As Ff climbs down from 230 the owner of the Saab has run up to theappliance and is standing right next to him. The driver is in shock but uninjuredso Ff sent him to “wait with the vehicle” – (Ff later clarifiedthat he sent this driver towards the unknown car (identified later as possibly asilver Nissan Micra) parked further down the carriageway, south of theincident).

Fire Control mobilises 231 to return at 21.35.38 and alerts Hitchin 320 at21.35.57.

21.35.42 The female Highways Agency Traffic Officer sends an urgentassistance message via her handset radio to Highways Agency Control that a“fire engine has been hit and people are injured – the whole carriageway isclosed.”

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The female Highways Traffic Officer is not injured and is instructed by Ffto fend off as much of the motorway as possible. A car has already

stopped in lane two of the dual carriageway and the Highways Officer instructsthis car to remain there. In this car is an off-duty London paramedic who getsout offering help.

Ff approaches LFf with a first aid bag and gives him abandage. LFf tells him he is OK and to help Ff who he can seeis with SubO Mallaghan.

Ff approaches the Highways Officers who are now standing togetherand checks they are OK and they instruct him to help his colleagues.

At some point after the crash LFf remembers talking on the radio to LFf but cannot recall the time or what he said.

Below is a photograph (fig 5) taken of the scene post-collision during theaccident investigation, showing the position of the fire appliance, the Saab andin the distance the VW Golf facing the wrong way across lane one.

StnO is alerted about the collision by Fire Control and is mobile at21.37.55.

21.38.39 Fire Control inform the Ambulance Service.

21.38.41 231 books mobile to incident.

Fig 5Scene postcollisionshowingposition of230, Saaband Golf

SAAB

GOLF

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The uninjured female Highways Agency Traffic Officer continues to sendmessages to HA Control centre updating on the situation and HA Control liaisewith HFRS Command and Control, the ambulance service and the police.

21.39.54 Baldock’s second appliance, 320, books mobile to incident with a crewof 5.

The driver of the VW Golf remained in the car. Ff checks on this driver.

Ff goes to the appliance to get “the RTC kit off – Lukas power pack,ram support etc.” Ff returns to the appliance and collects thespreaders.

Ff thinks that 230 is “too close” to the Saab so he gets in and movesit forward about 8-10 feet.

An off-duty London paramedic/nurse held up in the stationary traffic assists Ff and Ff with SubO Mallaghan. The paramedic advises them

that SubO Mallaghan needs “getting out” and Ff puts the spreadersunder the near-side front wheel and lifts the vehicle sufficiently for theparamedic to commence CPR.

231 arrived at the incident at 21.40.30. They park in the 'fend off' positionacross both lanes of the A1(M) motorway, (see Appendix 1 Fig IV). LFf

notices that the Highways Agency vehicle had not moved into their“original fend off position.”

LFf gets off the appliance and sees a firefighter laying on the groundwith a bandage to his head and SubO Mallaghan with “an ambulance womanworking on him.”

Ff gets off the appliance and has a quick look at the vehicle in lane 1-2and can see the driver upright and calling out. He goes over to LFf

LFf is aware of the arrival of 231 and Ff gives him anotherbandage to put on his head. Ff sees SubO Mallaghan under the front ofthe Saab. As he gets closer he can see SubO Mallaghan is trapped and is notbreathing. Ff assists the off-duty London paramedic inserting an airwayand using the bag valve mask with the paramedic doing chest compressions.

Ff goes to LFf who tells her SubO Mallaghan is under the carand she sees Ff and the paramedic working on SubO Mallaghan. Shefetches the oxygen mask at Ff request and then she collects airmats.

21.42.01 LFf sends an informative message from 231 “prioritymake pumps 4.”

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Ff sends a message by mobile phone to Control stating there are twofirefighters on the roadway and an ambulance and police are required.

LFf gets the crew to provide more blocks and he checks the driverof the second collision vehicle (VW Golf) who is complaining of pains to hischest but he appears ‘OK’ so LFf goes to speak to Ff

21.42.16 StnO arrives and sees the orange lights of the HighwaysAgency vehicle and the blue lights of the fire appliance further up the road.

StnO sees LFf on the hard shoulder and immediately requestsControl mobilise the attendance of a DO due to the seriousness of the incident.

LFf approaches Ff who advises him that they need to getSubO Mallaghan “out fast.” The rest of the Stevenage crew are working tostabilise the vehicle and place airmats whilst Ff continues to work onSubO Mallaghan. SubO Mallaghan begins breathing and gags on the airwaybut then stops breathing again. Another paramedic crew arrive and take overfrom Ff so he returns to LFf

StnO is briefed by LFf StnO sees that SubOMallaghan is being attended to by two ambulance personnel and efforts arebeing made to raise the vehicle to release SubO Mallaghan. StnO ascertains LFf is conscious and talking.

21.43.01 LFf sends an informative requesting the RSU.

LFf sees Hitchin approaching and radios for their blocks.

21.44.41 320 Hitchin is in attendance - SubO with a crew of 5: Ff (driver) Ff Ff and LFf

StnO is now Incident Commander and appoints SubO to behis Command Support Officer. 320 is made the Control Point and fire groundradio contact maintained through Ff

Hitchin crew, Ff Ff and LFf provide blocks and airmatsand assist Ff and Ff to raise the Saab.

Baldock 310 is alerted and books mobile at 21.45.34.

21.46.23 Hatfield RSU is mobile to incident (alerted 21.43.52) with OiC LFf and Ff

Whilst Ff is dealing with LFf he notices that the driver of the Golfis slumped over his steering wheel so he goes over, opens his door and raiseshis head. Ff looks for assistance but everyone is working on the Saab.StnO briefly comes over and advises Ff that other crews arecoming.

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21.46.33 An ambulance arrives on scene.

21.48.53 Two police units arrive on scene.

21.49.04 Ff sends an informative message by mobile phone from 231for LFf which Control logs as “2 cars in collision on motorway; 2firefighters injured plus 1 civilian suffering from head injuries and trapped.Lukas airmats in use. StnO in charge. Make ambulances 3.”

21.50.16 Hitchin 321 is in attendance – OiC , Ff and Ff

StnO instructs SubO to stay with LFf who is layingmotionless and has a lot of blood around his head. SubO asks Ff

to get the first aid kit and LFf comes over to assist.

21.50.23 DO arrives and can see the activity and that StnO isheavily involved in command and control.

DO liaises with Police Inspector r who appraises him of thesituation and advises him that there are four persons with varying degrees ofinjuries (2 firefighters, 1 Highways Agency and 1 public). The focus of attentionis on the two firefighters and male occupant of the VW Golf.

StnO gives DO a concise briefing and DO advises him he istaking over Incident Command (IC) and obtained an IC surcoat from LFf

DO advises StnO to continue to coordinate withinthe rescue area. DO observes the urgent activity surrounding SubOMallaghan’s treatment.

21.52.45 Baldock first appliance, 310, in attendance – SubO Ff driving, LFf and Ff

Ff sends a radio message to Baldock 310 requesting their airmatsurgently. He fetches a second spinal board and takes it to the scene ofoperations but, as there are a lot of people working on the Saab, Ff goes to assist the firefighter attending the casualty in the VW Golf. The casualtyis not trapped and wants to get out of the vehicle so the firefighters explain heneeds to stay there and be checked by paramedics. The photographs overleaf(fig 6 and 7) show the VW Golf which is facing the wrong way across lane one ofthe motorway.

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SubO reports to StnO and sees firefighters and ambulance staffattending to the injured firefighter on the hard shoulder. Baldock crew areasked to provide airmats urgently and SubO returns to 310 and gets LFf

and Ff to bring equipment to the main scene of operations.

On arrival the gear is no longer required so SubO goes to the othervehicle (VW Golf) to check the situation where Ff and an ambulancetechnician are dealing with the driver of the vehicle, who is injured but notphysically trapped. Ff is relieved by a Baldock firefighter and Ff assists a paramedic in applying a stiff neck collar to the casualty.

21.53.33 Control request three ambulances.

Fig 6Front view ofVW Golf postcollision

Fig 7Side view ofVW Golffacing wrongway oncarriageway

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DO checks with the paramedics assisting the driver of the VW Golf andthey indicate to DO they do not need additional assistance, confirmingthat the driver is not trapped and they are stabilising him.

SubO gets a spinal board from an ambulance and a stretcher and takesthem to the Saab. Several firefighters are assisting in the removal of SubOMallaghan: they are Ff Ff Ff Ff Ff and LFf The vehicle is raised and SubO Mallaghan is slid out and putonto the spinal board where the Ambulance crews work to try and stabilise him.SubO Ff Ff and Ff hold the stretcher with SubOMallaghan on it whilst the ambulance service get the straps on the stretcher.

21.58.59 Hatfield RSU is in attendance with riders LFf and Ff

22.00.25 An informative from 320 is sent “further information – Station Officer – details as previous steady progress being made. Tactical Mode

Oscar.”

SubO Mallaghan is conveyed to Lister hospital.

Ff goes to the Highways Officers who are still next to the crash barrierand gives them a bottle of water from the appliance. Ff learns thatone of them is injured and he informs a member of the ambulance service.

LFf goes to LFf who is now lying alone on the hard shoulder. Shesees a dressing has been put on his head and she and stabilise himwith a stiff neck collar and oxygen. They cut off LFf fire kit and movehim to a more comfortable position. Ff points out that another man is stilltrapped by his injuries in his car (VW Golf) and LFf instructs Ff togather resources and start the extrication of this driver.

Ff is chocking the Golf and checks the hose reel which is not chargedso he traces it back to the Stevenage appliance (230) and asks a Stevenagefirefighter to charge it. The Stevenage firefighter (possibly Ff returnsand says it isn’t possible. Ff states that LFf has been laying ontop of it and the hose reel had been used for the car fire. Ff runs outa hose reel from 320 and asks Ff to engage the pump and charge thereel.

At some point Ff and Ff from Baldock get the hose reel fromthe off-side of 230 and charge it ready for use.

22.05.15 LFf sends an informative by mobile phone from 231 “ DO now OIC; 1 firefighter released and being taken to hospital by

ambulance; 1 firefighter still trapped expected to be released soon; driver ofother vehicle still trapped by injuries ambulance still working.” (As per ControlLog on page 85).

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LFf is moved onto a stretcher and handed over to the ambulance andtransported to Lister Hospital.

More paramedics arrive and they discuss how to remove the casualty from theGolf, deciding to bring him out on a spinal board through the rear of thehatchback. Ff Ff , Ff LFf and Ff workto remove the driver of the VW Golf on a spinal board through the rearhatchback.

Ff co-ordinates with the ambulance until the casualty from the Golf istransferred to Lister Hospital.

DO liaises with StnO regarding the welfare of the Stevenagecrew and agree to get them away from the incident as soon as possible anddiscuss securing the scene for investigation purposes.

22.07.39 SubO sends an informative message from 320 that a flexi-duty officer is required at Stevenage Fire Station to liaise and thatOccupational Health needs to be informed of two firefighters injured.

DO takes a call from ACO and appraises him of the situation.DO liaises with the Paramedic Press Officer, other paramedics, policeofficers and firefighters. DO notices another car with hazard lights onparked approximately 100m in front of 230 along the hard shoulder. Ff

informs him that this was parked there when 230 arrives. DO notes later that this car had driven away.

ACO arrives at the incident at 22.13.43.

DO is approached by Police Inspector who informs him that thehospital has informed him that SubO Mallaghan condition is not good and thathe is not expected to pull through. ACO is nearby talking on hismobile phone so DO interrupts this phone call to advise the ACO of thismessage.

ACO leaves the incident to collect SubO Mallaghan’s wife and takeher to the hospital.

22.16.18 StnO arrives at the incident with StnO who is off-duty but they leave to go to Lister Hospital where SubO Mallaghan has beentaken.

At 22.17.18 the Highways Agency Traffic Officer is taken to hospital as aprecaution.

22.19.47 320 sends an informative from DO requesting a flexi-dutyofficer to attend Lister Hospital, an officer required for the incidentinvestigation at the scene and clarifies the names of the firefighters involved.

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2

2

2

5

1

7 8 4 9

10

11

1

2

2

2

2

3 5

HA 2

21

At 22.28.37 Stevenage crews leave the scene on 231 to return to StevenageFire Station.

DO is approached by a paramedic returning to the scene who hadearlier been treating SubO Mallaghan and accompanied him to the hospital.She advises DO that there is an excellent trauma care team at thehospital providing treatment for SubO Mallaghan.

All casualties have been removed from the scene and Police Inspector speaks to DO again and advises him of the bad news that SubOMallaghan has passed away at the hospital. DO passes this informationon to StnO They discuss how to break the news to the crews still at thescene and SubO is instructed by DO to gather all firefighterstogether so he can speak with them.

22.53.29 The Police commence their accident investigation.

22.53.43 DCO is informed.

23.05.46 310 Baldock leaves the incident.

23.08.23 StnO attends the incident to carry out the accident investigation. StnO takes photographs and writes upa summary of the event.

23.10.52 321 Hitchin leaves the incident.

23.11.22 320 Hitchin leaves the incident.

23.12.42 185 Hatfield leaves the incident.

23.28.40 STOP MESSAGE: Sierra 01: 1 person code 1; 3 persons code 2.

00.48.00 230 Left in situ for the police Road Crash Investigation.

03.34.38 Hertford 240 removes 230 from the scene.

03.48.45 Stn O clear of incident.

03.49.28 Stn O clear of incident.

03.49.34 DO clear of incident.

11

1

2

2

2

2

22

2

2

1

1

1

Par 1


22

23

3 Operational ProceduresThis section provides an abridgement of the National and Local proceduralguidance relating to the Fire and Rescue Service when attending incidents onthe roadway, and in particular, on the motorways. It also presents anoverview of the role of the Highways Agency, and how it operates alongsidethe Fire and Rescue Service at any such incident.

This section will then seek to provide a detailed operational account ofincident number 10644, leading up to the road traffic collision thatsubsequently led to the death of SubO Paul Mallaghan, and the seriousinjuries to LFf a Highways Agency Traffic Officer, and a member ofthe public.

There is a separate section on the findings based on the facts revealed.

The full list of national and local procedural guidance documentation isidentified in a bibliography at the end of the report.

Nationally Agreed Fire Service Procedures for Incidentson Roadways

The Fire and Rescue Service Manual Volume 2, entitled Fire ServiceOperations – Incidents Involving Rescue from Road Vehicles was issued toHFRS in May 2007 under the authority of the Department for Communitiesand Local Government (DCLG). The manual is designed to promote currentbest practice, and reflects the most up to date information sourced fromvehicle specialists.

The manual author acknowledges assistance from a number of contributingauthorities for their invaluable assistance in completing the publication.

The organisations include:

The Association of Chief Police Officers Chief Fire Officers Association Operations CommitteeFire Brigades’ UnionThe Highways Agency Her Majesty’s Fire Service Inspectorate Operational Practices Her Majesty’s Fire Service Inspectorate Publications Her Majesty’s Fire Service Inspectorate Scotland London Fire and Emergency Planning Authority The Fire Service College The Scottish Fire Service College

3.1

1


24

The manual is used in conjunction with the policy guidance of individual Fireand Rescue Services. It replaced the guidance provided in Manual ofFiremanship Book 12 Chapter 3, and also FRS Manual Volume 4 ‘Foundation,Training and Development’ Chapter 4.

The manual provides detailed guidance in the following areas:

Vehicle design and constructionDealing with incidentsSafety proceduresOperational proceduresExtrication equipment; medical considerations and trauma careIntegrated personal development systems

Significantly, Chapter 4 of the manual provides guidance on motorwayprocedures. Chapter 4.4 gives general details on:

The make up of carriageways, junctions and interchangesService areasEmergency crossingsEmergency telephonesMarker postsMotorway crash barriers (including the types of barriers in use)

It provides guidance when approaching an incident on the motorway and thepositioning of fire appliances and other responders. This guidance is thesame as the guidance that appears in the Policing Motorways 2006 Manualproduced on behalf of The Association of Chief Police Officers (ACPO).

It also provides guidance on the 'fend off' positions for fire appliances andconing, including signage and use of emergency lighting when attending anincident. It details the responsibility of the police in conjunction withHighways Agency Traffic Officers (HATO) to provide a safe working area forother services.

It states that subsequent emergency services arriving at an incident will bedirected by the police to the safest position to park their vehicle consideringthe dangers of passing traffic, and the need for those attending to performtheir roles.

It goes on to state that if the Police are not in attendance on arrival of theFire and Rescue Service, an appliance should be positioned as a warning toapproaching traffic in a fend off position 50m to the rear of the incident. Thisis the distance recommended to give adequate warning to fast moving trafficand should be adhered to wherever possible.

Further, it gives detailed guidance on what procedures to adopt when

25

attending an incident on a motorway. It states that there are two mainmethods of positioning emergency service vehicles in the carriageway. Both ofthe following procedures are in use by the Police and local planning will assistin identifying the one that the local police force will adopt.

‘In line’ The emergency vehicle is parallel to the running lanes of the carriageway thismaximises rear facing lighting due to the size of the car compared to thecarriageway. Patrols should be aware that to the approaching traffic thestationary in line vehicle could appear to be moving with the traffic.

‘Fend off’The vehicle is angled pointing front end towards the carriageway in thedirection the traffic should pass (see Appendix 1 Fig i). This method willeffectively fill the lane to be closed and will act as a visual reinforcement ofthe cone taper. It will appear stationary to the approaching traffic, but theeffectiveness of the lighting will be reduced.

The Fire Service Manual also provides detailed instructions for use of coningand signing and use of emergency lighting.

Section 4.4.13 of the Fire Service Manual ‘Positioning of fire appliances andother responders states:

“It is the responsibility of the police in conjunction with the HATOs to providea safe working area for other services. Emergency services arriving at thescene will be directed to the best position in which to stop their vehicles,taking into account the danger of passing traffic and the needs of thoseattending to perform their role. Priority should be given to life saving andcasualty handling requirements.

Emergency vehicles will be directed to stop within the coned off area beyondthe police vehicle(s) which will be positioned to provide advance warning. The50 metre area between the police vehicle and the incident should be left clearfor the Fire and Rescue Service to position their appliances. This should allowsufficient space for specialist firefighting or extrication equipment to bedeployed. In the event of a fire where the Fire and Rescue Service is inattendance, responsibility for fighting the fire rests with the senior fire officer.The police are responsible for assisting with any reasonable request.

The ambulances will usually be positioned beyond the incident. This allowsthe safer loading of casualties into the ambulances and enables them to leavemore quickly. The cooperation of all emergency services and other partners isrequired to maintain free passage to and from the scene, and to keep trafficmoving at a safe speed. The police are responsible for the overall control andscene management. They must inform partners at the earliest opportunity ofany special road conditions at the scene.’’


26

Guidance on Policing Motorways 2006 Manual (GPMM)

This document was produced by the National Centre for Policing Excellence(NCPE) on behalf of the Association of Chief Police Officers (ACPO) and isupdated according to legislative and policy changes and re-released asrequired.

The NCPE was established by the Police Reform Act 2002. As part of itsremit the NCPE was required to develop policing doctrine, includingguidance, in consultation with ACPO, the Home Office and the Police Service.

The Guidance on Policing Motorways 2006 Manual (GPMM) produced by theNCPE is used by Chief Police Officers to shape Police responses to ensurethat the general public experience consistent levels of service.

The GPMM advises that Police should work closely with the other attendingunits to ensure that they adopt the correct parking position and advises theprocedures for blue light usage at the scene.

It reaffirms that the priority for the Fire and Rescue Service is the immediaterescue of injured people and the extinguishment of fires. Police will informthe Fire and Rescue Service and any other partner of any known hazardspresent at incidents.

The GPMM advises that when a vehicle is on fire the police should:

Set matrix signs to close the lane containing the burning vehicle and adjacent lanes.

Close lane one when the burning vehicle is on the hard shoulder so that the Fire and Rescue Service can carry out their duties.

Cone and sign the lane(s), having regard to their own safety, and create a sterile working area for the Fire and Rescue Service. If the Fire and Rescue Service are required in a particular position, sufficient space must be created.

Consider the need to increase the number of lanes closed and the method of coning required to achieve this, should the situation change for the worse.

Consider their own and the public’s safety if smoke is present as it is likely to be highly toxic and can affect a wide area.

Additionally, the GPMM explains that there was joint working between ACPOand the Highways Agency in 2002 and it was agreed that the Agency shouldbecome more involved in the operational management of the Agency’smotorway network. The joint operational goals for the police and the

3.2

27

Highways Agency are given in detail in the document ‘Highways Agency andACPO (2005) The Network Operations National Guidance Framework’.

In summary this is to improve road safety, reduce incident related congestionand free up police resources. Further details relating to the relationshipbetween the Highways Agency and the Fire and Rescue Service are coveredlater in this section.

A Guide to Operational Risk Assessment - Fire Service Guide Volume 3

To enable dynamic management of risk at operational incidents, the abovenational generic risk assessment guide has been produced and was firstissued to Fire and Rescue Services in 1998 previously under Her Majesty’s FireService Inspectorate. This is now under the authority of the Department forCommunities and Local Government and is currently undergoing a series ofreviews by a national working group. Generic Risk Assessment (GRA) 4.1entitled ‘Incidents Involving Transport Systems – Roads’ has not been revisedor updated since its first issue.

This GRA highlights the hazards, risks and control measures that relate toincidents on roadways that include vehicle accidents and vehicle fires.

Significant hazards and risks identified are:

Moving trafficThe vehicles involved and their loadsThe occupantsThe site conditions Use of specialist rescue equipment

The key control measures identified in the risk assessment are:

Pre-planning, which includes equipment carried on appliances and training.

Safe systems of work, which includes the positioning of appliances and the assessment details that the police officers at the scene of an incident will be in control of.

Traffic movement. It is recommended that the Fire Service Incident Commander should take account of police views in the positioning of appliances.

The Generic Risk Assessment 4.1 provides a list of considerations for theIncident Commander for incidents on roadways, which includes:

3.3


28

Appliance approach should be slow and controlled for the following reasons:

Adverse weather and road conditions including visibilityObstacles and debris on the roadCasualties wandering or thrown onto the roadwayEnable drop off of a firefighter to deploy police sign 900m from

incident if the police are not in attendance. A slow approach will also enable the Incident Commander time to make a brief assessment.

The position of fire appliances will normally be 50m before the incident at ashallow angle to fend off approaching traffic with the fire appliancesremaining within the confines of the affected lanes.

For motorway incidents where police are not in attendance, appliancepositioning may vary depending on which of the lanes are involved. It statesthat further guidance is provided within the Manual of Firemanship Book 12.

(NB: This book has now been superseded by Fire and Rescue Service ManualVolume 2 Fire Service Operations - Incidents Involving Rescue from RoadVehicles as outlined above).

The Generic Risk assessment 4.1 also includes instructions for the FireService Incident Commander to ensure that all Fire Service personnel wearappropriate protective equipment in addition to normal fire kit, e.g. highconspicuity jackets and gloves.

Further initial considerations from the Generic Risk Assessment 4.1 include:

That police in attendance will be responsible for the traffic management. Ifthey are not in attendance then fire service vehicles should ‘fend off’ at ashallow angle 50m from the incident, using the police signs: ‘Accident’,‘Accident Slow’ at 900, 600, 300m respectively.

Cones should be laid out for a distance of 100m per lane from theobstruction. In poor visibility lighting should be considered for the incidentarea.

When there are multiple appliances in attendance at an incident, it isadvisable that only the appliances at the rear should be showing blueflashing lights. In fog, fog lights should be used. At night or in fog, searchlights should be used to illuminate ‘fend off’ appliances.

Firefighting equipment should be laid out to cover the whole of the incidentarea and an assessment should be made to ensure that adequate resourcesare on the scene. If not, what further assistance is required should be basedupon the number of casualties, the number of persons trapped, and specialrisks e.g. vehicles carrying hazardous loads, information retrieval, likelihood

29

3.4

3.4.1

of fire, fire spread and water supplies, medical assistance required, specialistequipment and appliances required.

Crew Safety Crews should be briefed on the plan of action and safety considerationsincluding dismounting the appliance on the safe side, and personnel stayingwithin the coned area and avoiding other lanes.

As the Incident developsFurther generic guidance is given in the event that the incident becomes moreinvolved.

Hertfordshire Fire and Rescue Policies and Procedures

Service Information System Operational Procedure - Incidents Involving RoadVehicles (Ops 2/30)

Following the introduction of the Hertfordshire Fire and Rescue Service(HFRS) Information System (SIS) in April 1999, the Service recognised thatService Information System documents need to be reviewed and updated on aregular basis. Currently, unless there are major changes to an operationalprocedure, all operational documents will be reviewed within a three yearperiod. SIS Ops 2/30 was issued on 14 June 2004. The replacement draft for2007, in line with the three year review, is being finalised to reflect theupdates in operational procedures highlighted in the newly issued Fire ServiceManual and will be circulated shortly.

The current procedural document provides detailed information on hazardsassociated with fires and accidents involving vehicles on motorways and otherroadways.

The Key Information in this document includes prompts for IncidentCommanders and advises considerations for initial actions when approachingan incident of this nature. It includes the following guidance:

If the Police are not in attendance fire crews should:

Fend off at a shallow angle at an appropriate distance for the class of road, and deploy ‘Police Slow’ signs.

Lay out cones at an appropriate distance from the incident. In poor visibility they should consider lighting for the incident area.

When there are multiple appliances in attendance at an incident, it is advisable that only the appliances at the rear should be showing a blue light. In fog, fog lights should be used. At night or in fog search lights should be used to illuminate ‘fend off’ appliances.


30

3.4.2

Have firefighting equipment laid out to cover whole of incident area.

Consider prioritising vehicles where persons are trapped when planning firefighting response.

Ensure that adequate resources are on the scene. If not, they should assess what assistance is required.

Appoint a Safety Officer.

Section 1 provides a warning on the potential hazards and dangers whenattending incidents on motorway carriageways. It gives information on therequirement to wear full personal protective clothing and high visibilitysurcoats. It advises fire service drivers and oncoming supervisory support todress on arrival before venturing on to the carriageway. It advises personneldismounting from appliances to ensure that they are on the side away frompassing traffic.

The SIS Ops 2/30 reflects the guidance issued in Book 12 Manual ofFiremanship, and advises on the dangers of carriageways including theproper PPE to be worn and how to dismount from the fire appliancecomplementing Generic Risk Assessment 4.1 as follows:

“It cannot be over emphasised that there is always danger from fast movingtraffic. All personnel must be constantly alert to this fact when working andmoving about the incident. The speed and weight of vehicles will varydepending upon the type of road and time of day. However, on mostoccasions the likelihood of being struck by a vehicle travelling at speed ishigh.”

The Highways Agency and the Fire and Rescue Service – Partnership Working

The Highways Agency was established in 1994, and is an executive agency ofthe Department of Transport and is responsible for operating, maintainingand improving the strategic road network in England on behalf of theSecretary of State for Transport.

The Secretary of State for Transport is responsible for overall Governmentpolicy on motorway and trunk roads in England and for determining thestrategic framework and the financial resources within which it operates.The Agency’s purpose is to provide safe and reliable long distance journeyson strategic national routes by managing the traffic using roads as well asadministering the network as a public asset.

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3.4.3

The aims, objectives and values of the Highways Agency are to deliver highquality services to customers by reducing congestion, improving reliability andimproving road safety while respecting the environment and seeking feedbackfrom customers.

The Fire and Rescue Service and Highways Agency have a joint interest inensuring they deliver the best possible service to members of the publicinvolved in fires, accidents or other incidents on the motorway and trunk roadnetwork. Both organisations acknowledge the need to develop the partnershipto maximise synergy and benefit the management of incidents on the roadnetwork.

The Highways Agency has been charged by the Secretary of State withdeveloping its role as a network operator to achieve greater efficiency intraffic and congestion management and to help the existing trunk road systemwork more efficiently.

As part of this objective the Highways Agency has introduced a Traffic OfficersService. Highways Agency Traffic Officers (HATO) are uniformed officials thatpatrol the Secretary of State’s motorways and selected trunk roads inEngland. They undertake a range of traffic management functions such asdealing with breakdowns, obstructions, debris and supporting the police atmajor incidents. They have the power to set variable message signs and stopor direct traffic in order to manage traffic and help to keep it moving.

The Fire and Rescue Service deals with fires and other emergencies. Theyalso carry out other various emergency planning activities and are governedby the Fire and Rescue Services Act which requires Fire Authorities to makeprovision for firefighting, road traffic collisions, fire safety and otheremergencies. The latest Fire and Rescue Services Act 2004, places a legalrequirement on the Fire and Rescue Service to make provision for rescuingpeople in the event of road traffic accidents (now termed collisions) andprotecting people from serious harm to the extent that it considers itreasonable to do so in the event of a road traffic accident.

National Memorandum of Understanding

A national Memorandum of Understanding (MOU) between the HighwaysAgency and Chief Fire Officers Association (CFOA) sets out a purpose andscope that ensures proper partnership working. The document seeks toprovide a framework for the Fire and Rescue Service and the HighwaysAgency to work in partnership.

The aim of the joint working between the Fire and Rescue Service and theHighways Agency is to develop a structured working relationship in order thateach organisation understands in more depth the issues that face each otherand provide a framework to manage and resolve them. It also aims to developareas of mutual interest and opportunities for joint working.


32

The MOU is not intended by either party to be legally binding as some or allof the arrangements/procedures referred to in the MOU may be terminatedin writing by either party though they will use their best endeavour to givereasonable notice to the other party of such termination.

The Police Service has responsibility for the co-ordination of the emergencyservices at a major incident. The Highways Agency Traffic Officers (HATOs)will assess, plan and implement the restoration to normality of thecarriageway and infrastructure at the scene, and undertake trafficmanagement including the approach to the incident scene.

Traffic officers will support the implementation and management by police ofa safe working environment for emergency services. For minor incidents e.g.embankment fires, single vehicle fires etc, it will not always be appropriatefor police to attend.

For minor incidents the Traffic Officers will implement and manage thecreation of a safe working environment for the emergency services. Ifappropriate it will arrange for incident support units to provide additionalsupport by removing debris or implementing a full closure of the roadway.

The Eastern Region of the Chief Fire Officers Association, which includesHertfordshire Fire and Rescue Service, has also signed up to a regional MOUwith the Highways Agency. The MOU indicates the background, purpose andscope of the aims of the joint partnership working between the HighwaysAgency and the Fire and Rescue Service.

The purpose of this Regional MOU is to ensure understanding betweenHertfordshire Fire and Rescue Service and the Highways Agency in themanagement of any incident on a “fast road” within the county. Thisdocument aims to ensure that both agencies are clear as to their individualresponsibilities and duties when working on the highway. It also provides guidance as detailed below:

Liaison meetings - Strategic regional meetings between the lead officersof each organisation that will take place every six months to discussplanning, management, procedural, intelligence and performance issues.Matters arising locally considered being of a regional or national nature willbe forwarded to the lead officers by the respective agency/service.

Notification of Incidents - Calls to incidents on the road network that arereceived by Fire Service Control Rooms will be passed to local county PoliceControl Rooms. The local county Police Control Room will be responsible fornotifying the Highways Agency Regional Control Centre at South Mimms ifappropriate.

Calls received at the Highways Agency Regional Control Centre will bediscussed with the permanently present Police Liaison Officer and passed to

33

3.4.4

the relevant fire service control room as appropriate. Road closures and trafficmanagement, although powers exist under the Fire Services Act 2004 for FireServices to close roads and manage traffic if required. The expectation is thatHighways Agency personnel will be responsible for closures and trafficmanagement at incidents on motorways in liaison with the Police and Fire andRescue Service.

Information Sharing - Information dissemination or matters affecting morethan one Fire Service within the region will be dealt with by the Regional LeadOfficers.

Training and Exercises - Any training events or exercises affecting morethan one fire service will be co-ordinated through the Regional Lead Officers.

In August 2005 HFRS issued a Station Memorandum 10/2005 to all personnel.This detailed the roll out of the Highways Agency Traffic Officer Service inHertfordshire. Attached to the Station Memorandum was a leaflet giving briefdetails of the ‘Traffic Officers Service’. In addition it gave details of a DVDproduced by the Highways Agency that has been placed on HFRS’ intranet siteto enable personnel to familiarise themselves with the role of the HighwaysAgency.

Hertfordshire Fire and Rescue Service also arranged a series offamiliarisation visits to the South Mimms Regional Control Centre forpersonnel working within the M25 catchment area. This provided anopportunity to discuss how fire and rescue operations work with HATO andhow we can assist each other at incidents in the future. These were notservice-wide familiarisation visits and did not include Stevenage.

Variable Message Signs

As mentioned, the Highways Agency have the power to set variable messagesigns and stop or direct traffic in order to manage traffic and help keep itmoving.

Issues have subsequently been discussed with the Highways Agency duringthis investigation in relation to the setting of the halogen matrix signs abovethe motorway. These provide messages and warnings to road users includingspeed restrictions. Speed restrictions and messages can appear in orange,meaning they are advisory, or in red which are mandatory. For any accidentreported to the Highways Agency these signs will be set at an advisory 50mph.Only the Highways Agency or the Police have the authority to reduce thespeeds further. The process for setting the signs ensures that the matrix signson approach to an incident will be set to display incrementally decreasingadvisory speeds (e.g. 50, 40, 30, down to 20mph) in order that drivers are giventime to reduce their speed.

At 19.56 on the evening of 16 June 2007, there was a report of what has been


34

described by the Highways Agency as a ‘flooding incident’ on both thenorthbound carriageway junction 7 to 8 and the southbound carriagewayjunction 8 to 7 of the A1(M). This resulted in the signs being set to reducethe speeds to 50mph. These speed restrictions ended at 21.08.50.

It has been confirmed from the Highways Agency signal logs that on arrivalof the two fire appliances at Incident no 10644 (the car fire), at 21.24.58 and21.25.47 respectively, there were no advisory speed settings on the overheadmatrix signs for either carriageway.

The Highways Agency Traffic Officers arrived at the scene at 21.28.59 hrs.They immediately made a request to the Highways Control Centre to set themotorway matrix signs and reduce the speed of traffic in the vicinity. Thematrix signs were set to 50mph at 21.33.27.

Following the collision a radio message was sent by a HATO at the scene totheir Control at 21.35.42 advising them of the collision and the signs werethen re-set to 20mph at 21.38.32.

During this investigation the Highways Agency advised that the Fire andRescue Service can directly make a request to the Highways Agency Controlthat matrix signs are set to reduce the speed (this will be done at thestandard 50mph). Enquiries have revealed that this is not commonknowledge in the Fire and Rescue Service.

The Highways Agency will undertake to raise this issue at a National Signsand Signals Users Group and request that the Fire Service can be givenauthority to set the speed.

The Highways Agency account of their Operational Procedure atIncident no. 10644

On Saturday, 16 June 2007 the Highways Agency (HA) were assigned via theircontrol centre to attend a vehicle (Saab) on fire at location A1(M) Junction 8slip road southbound.

The Highways Agency Traffic Officers (HATO) vehicle arrived at 21:28. BothStevenage fire appliances call signs 230 and 231, were already on scene anddealing with the incident. All activity was confined to the hard shoulder. 230fire appliance was parked on the main carriageway hard shoulderapproximately 15m in front of the Saab. According to LFf Fireappliance 231 was parked within the slip road leading to the maincarriageway. 230 was in the ‘fend off’ position as illustrated in Fig i opposite.The exact location is unknown but the drawing provides an illustration ofthe positioning only gathered from individuals’ contemporaneous notes.

As the HATO vehicle approached, SubO Mallaghan allowed 231 to leave thescene. The HATO vehicle took up the fend off position 30m, (according to the

3.5

2

35

Fig i SCENE @ 21:25:47

Representation only of thepositions of 231, the Saab,230 and the “secondvehicle.”


36

HATOs’ account of the incident), behind the Saab displaying full emergencylighting, at low power, appropriate for the location and darkness level. TheHATO vehicle was parked in the ‘in line’ fend off position, on the slip roadhard shoulder. Fig ii opposite.

The HA officers exited the HATO vehicle and liaised with the fire officers atthe scene to establish if the vehicle fire had been extinguished and was readyfor recovery.

The fire crew of 230 were in the process of ensuring that the Saab was safeto leave. A HA officer also spoke to the driver of the Saab. At this point bothHighways Traffic Officers were standing behind the hard shoulder barrier.

A HATO had decided that the car needed an immediate removal placed on it,due to the location and the fact it was unlit. At 21.30 the HATO radioed theircontrol to ask for them to arrange this.

SubO Mallaghan was standing in front of the Saab apparently trying toestablish the cause of the fire and the extent of the damage to the vehicle.One of the HATOs collected the driver’s name and mobile telephone number;this was being done behind the hard shoulder barrier.

The other HATO was speaking to LFf adjacent to the Saab when atapproximately 21:35 the Saab was impacted from the rear by a passing carfrom the main carriageway. LFf was propelled into the HATO by theimpact, which in turn pushed the HATO over the crash barrier. Both LFf

and the HATO were injured. The Saab travelled approximately 15mfurther up the main carriageway trapping SubO Mallaghan beneath the frontof the car as it stopped.

The drawing, Fig iii on page 38, is not based on any exact scientificmeasurements but taken from witness estimates of the distances andphotographs of the scene post-collision.

The Service do not know which lane the VW Golf had been travelling in on theA1(M) before it left the main carriageway and entered the hard shoulder,hitting the Saab.

Fig iii on page 38 - The uninjured HATO called the HA Control Centrerequesting urgent assistance via her handset radio, explaining that therewere serious injuries to fire officers, a HATO and also the driver of aVolkswagen Golf, (the vehicle that had caused the subsequent impact).

1

1

1

37

Fig ii SCENE @ 21:29:01

Representation only of thepositions of the HighwaysAgency Vehicle, the Saab,230 and the “secondvehicle.”


38

Fig iii SCENE @ 21:35:24

Representation only of thepositions of the HighwaysAgency Vehicle, the Saab,230, the Golf and the“second vehicle.”

39

4 Clothing, Equipment,Vehicles andCommunications

4.1

4.1.1

4.1.2

The purpose of this section is to analyse whether adequate and appropriateequipment was available and/or used to control the risks relating to theoriginal incident – a car fire on the hard shoulder of the A1(M) – and thesubsequent incident – a multi-vehicle road traffic collision involving personstrapped.

Personal Protective Clothing

Under the requirements of the Personal Protective Equipment (PPE) at WorkRegulations 1992 HFRS supplies appropriate protective clothing in the form offirefighting kit and associated wear to all operational personnel.

The Generic Risk Assessment 4.1 relates to fire services working at ‘IncidentsInvolving Transport Systems – Roads’ and this includes advice on crew safety(3.2.5.). It instructs the Incident Commander to ensure that all personnelwear appropriate PPE in addition to normal fire kit, for example highconspicuity jackets and gloves (heavy duty and/or surgical,) ear defenders, eyeprotection etc. and BA should be worn at vehicle fires.

Firefighting kit

HFRS provide firefighters with the personal protective clothing through a totalcare package arrangement with Cosalt Ballyclare. All the items comply withthe appropriate British and European standards for firefighting kit as follows.

Conspicuity Clothing

The fire tunic has reflective strips on the arms, body and legs. This complieswith the legal requirements to ensure safety during work on roads when wornwith a reflective high visibility surcoat or tabard.

Leggings tested to EN367 convective heat testsTunic as aboveBoots EN345Helmet EN166Gloves EN233 & EN366Fire hood EN13911


40

In addition, for use when working at road traffic collisions or car fires eachfire appliance carries six high visibility tabards or surcoats. These conformto the appropriate standard when worn with the fire kit. (See pictures below.)

Fire kit

High visibility surcoats/waistcoats

The legal standard for conspicuity clothing is BS EN471:1994 – (previouslyBS6629: 1985 and also referred to as BS EN471:2003) Table 1 Class 2 or 3.This must be worn at all times. Jackets with sleeves must be worn on dualcarriageway roads with a speed limit of 50mph or above, unless operativesstay within the working space at all times.

The colour of the background material should normally be fluorescent yellow(from table 2 of the BS EN471:1994) and the retro-reflective material shouldcomply with Table 5 of this standard. This requirement is based on peoplewho might be required to direct traffic.

Fire kitshowing high visibilityreflective strips

Three styles ofhigh visibilitysurcoats/waistcoatscurrently issued by HFRS

41

The HFRS waistcoat style hi-vis jacket (called a ‘surcoat’) is rated to Class 2but fulfils the requirement of Class 3 retroflective material at operationalincidents on dual carriageways with speed limits above 50mph. Class 2 is thelesser standard and is only suitable when it is worn in conjunction with the firetunic. There is an acceptance from the police that this level is suitablebecause firefighters work within the protected zone. HFRS issue differentcoloured surcoats in a white or white and yellow version. All yellow surcoatsare standard hi-vis, white and yellow are issued for Incident Command orCommand Support roles.

However, HFRS Incident Command surcoats do not comply with Class 3 orClass 2 because they are not all yellow in colour, although IncidentCommanders are unlikely to be asked to direct traffic because they workwithin the ‘protected zone’. The Incident Command surcoats comply to theFire Service national standards to identify the officer in command of theincident.

Other PPE

Disposable gloves are provided on all appliances for firefighters to use whenadministering first aid to protect against biological hazards. These are wornunder the fire gloves.

PPE worn at the Incident

According to their notes and further enquiries all firefighters wore their PPE –full fire kit in addition to their high visibility surcoats.

Sub Officer Mallaghan

It is almost certain from witness statements that SubO Mallaghan wascarrying his fire helmet in his hand at the time the VW Golf collided with theSaab. SubO Mallaghan’s fire helmet was photographed at the scene of theincident in two locations – once on top of a generator and once on the OiC seatin the fire appliance. It was impounded by HFRS and given to the Police as anexhibit on 21 June 2007. It was also photographed by the Health and SafetyDepartment prior to this and it showed signs of ‘new’ damage to the top.

According to the police, SubO Mallaghan was also wearing the OiC hi-vissurcoat over his fire tunic.

The police took SubO Mallaghan’s fire kit: fire boots, leggings, polo shirt,trousers and high-vis surcoat from Lister Hospital as exhibits on 16 June2007.

4.1.3

4.2

4.2.1


42

Leading Firefighter

At the time of the collision LFf was not wearing his fire helmet orgloves because he had taken them off to speak with the driver of the car.During the collision LFf sustained head injuries. He also sustained leginjuries and at one point said he could not feel his legs.

LFf had his fire kit cut at the incident by LFf and LFf inorder to make him more comfortable and to apply a stiff neck collar.

His fire tunic, over trousers and hi-vis surcoat were removed at ListerHospital and placed in a clear plastic bag which was handed to HFRS staff.These items were taken by Hertfordshire Police as exhibits on 21 June 2007.

LFf firefighting gloves were also impounded into a yellow bio-hazardbag and handed to the police as exhibits on 21 June 2007.

Other PPE

Disposable gloves were worn by firefighters as stated by LFf 310.This is standard practice by crews going to RTCs to protect against biologicalhazards when dealing with casualties.

Equipment

A range of equipment used during the incident.

Breathing Apparatus

Ff wore breathing apparatus, but was not ‘under air’ due to the factit was a very small ‘fire’.

Hose Reel

Ff used a hose reel jet from the near-side of 230 to put out thesmall fire in the car. Subsequently, later on into the incident Ff andFf pulled an additional hose reel from the off-side of 230 and chargedit ready for use.

Ff ran out hose reel from 320 to the VW Golf car and charged thehose reel.

RTC Equipment

The following equipment was referred to in some of the firefighters’contemporaneous notes.

Lukas equipment: spreaders, power pack, combi-toolRam support

4.2.2

4.2.3

4.3

4.3.1

4.3.2

4.3.3

1

1

1

1

1

5

5

3

11

6

6

13

1

43

Chocks and Blocks Air mats

Prior to the return of 231, the two uninjured firefighters – Ff and Ff– were utilising as much of the RTC equipment as they could from

230 to commence the lifting of the Saab – which according to their notesincluded: “Lukas, power pack, blocks etc.” “ram support” “spreaders.”

All the RTC equipment was utilised from 230 and 231 to lift the Saab car inorder to release SubO Mallaghan. In addition RTC equipment from otherappliances was used to supplement this and to assist in the removal of thedriver of the VW Golf.

First aid

LFf was administered oxygen therapy, fitted with a stiff-neck collar andgiven bandages for his head injuries during the incident by Ff Ff

and LFfs and

Ff assisted SubO Mallaghan by inserting an airway and used a bagvalve mask (BVM) and oxygen.

A stiff-neck collar was used for the occupant of the VW Golf.

Vehicles

Fire appliances

Stevenage had a spare fire appliance registration no: on the run onthe evening of the 16 June 2007. This was due to the fact that call-sign 230,fleet number: was with Venson - (HCC contracted vehicle maintenancecompany) - having a ‘B Service’. This is the major service to every appliancecarried out once a year.

Stevenage's other appliance, call-sign 231: fleet number was on therun as normal.

Maintenance and Servicing

DO confirmed in his statement that a post-incident inspection wasrequested by the police and carried out by StnO at the request of PC

StnO operated all 230’s rear lights and StnO confirmed to PC that all side and blue lights were operating when hearrived at the scene. All lights were functioning correctly.

4.3.4

4.4

4.4.1

4.4.2

1

1

1

22 2

2

11

3

3

5

3 6

Reg Removed

Reg Removed

Reg Removed


44

There is a Service history for this spare appliance which has been inspectedand the vehicle appears to have had no serious defects prior to the incident.Its last main service was undertaken by Venson in August 2006 but it alsohad minor ‘on-site (A)’ services in November 2006, January and May 2007.

Lighting and Conspicuity

StnO confirmed that the orange flashing lights of the Highwaysvehicle and the blue lights of the fire appliance were on during the incident.

There is a CFOA User Requirement Statement which allows Fire and RescueServices the right to choose their vehicle livery within any statutory provisionand to promote the use of Battenberg (red and yellow chequers) marking (asper CFOA policy published 25 May 2000) as an accepted example of goodpractice.

Statutory provision is made through the Conspicuity Order VTS 23/9/16/59,enacted on 5 July 2006, which refers to the use of yellow reflectivity to therear and side of the vehicle (this is the same order that permits the use ofred flashing lights to the rear of a stationary appliance).

Below is a picture (fig 8 ) of the rear of this appliance following the collisionshowing the conspicuity markings.

Guidance was offered by the Department for Transport (DfT) on how Fire andRescue Authorities may choose to comply and this guidance introduces thedescription of the ‘Battenberg’. The Order itself does not require adherenceto the DfT’s guidance.

In conclusion, HFRS appliances comply with all the current nationalrequirements.

Fig 8Rear of 230showingconspicuity (high visibility)markings

4.4.32

4.5

4.5.1

4.6

Safe systems of work at the incident

Positioning and fending off is covered under the Operational Proceduressection, but the circumstances at this incident led to the first appliance pullingin front of the Saab car and the second appliance (231) behind taking up the‘fend off’ position and parking at an angle to block the whole slip road onto thehard shoulder. See drawing Fig i on page 35.

The Highways Agency vehicle pulled in behind 231 just as they were leavingthe incident and adopted an ‘in line’ fend off position in the hard shoulder.See the drawing in Fig ii on page 37. The Highways Agency adopt differentfend off positions to the Fire Service.

Safety Signage

All fire appliances carry the followingsignage for use at RTCs, see pictureright (fig 9 ):

6 x orange and white traffic cones(approx. 470mm high)1 x blue and white ‘Police Slow’ sign1 x flashing blue beacon formounting on a traffic cone

None of this equipment was deployedat this incident, although Ff asked SubO Mallaghan if cones werewanted - SubO Mallaghan told himthat the Highways Agency would doit. The Highways Agency TrafficOfficers are responsible for trafficmanagement when they attendincidents.

Communications

LFf s hand-held radio was put into a bio-hazard bag because it wascontaminated with blood. He had used it after the collision to send a messageto 231. It was handed to the police as an exhibit on 21 June 2007. LFf

heard Ff make the priority message (at 21.35.24) from230 over the main-scheme radio and 231 mobilised back towards the A1 justas they receive the mobilising instruction from Command and Control at21.35.38.

Fireground radios were used during the incident to call for more equipmentfrom oncoming appliances. There were no reported problems experiencedwith reception.

45

Fig 9 Safety signage carried onappliances - police slow sign, cones andflashing beacon

1

12

1


46

During the incident when messages of a delicate nature needed to be sentcrews adhered to the Service procedures and used the appliance mobiletelephones.

Although Hitchin’s first pump were initially unaware of the full circumstancesof the developing incident until their arrival (they were mobilised to a carfire), Fire Command and Control did advise oncoming appliances via mobiletelephone that the original car fire incident now involved an RTC with Servicepersonnel injured.

There appeared to be no problems experienced in general withcommunications to and from the incident ground throughout the incident.

47

Hertfordshire Fire and Rescue Service Training Module 7

The Hertfordshire Fire and Rescue Service Training and Development Centrebased at Stevenage have produced Training Module 007 which givesinformation on general procedures during road traffic collisions.

This training module is based on the Foundation Training and DevelopmentBook Volume 4, issued by the Department for Communities and LocalGovernment. It aims to introduce the trainee to the general procedures to beadopted at road traffic collisions and working on the roadways.

All trainee firefighters are trained and assessed in line with this trainingmodule by qualified instructors as part of their ‘phase one’ training beforethey are assigned to operational stations.

The objective on completion of the module is to ensure that the trainee will beable to:

State the correct positioning of appliances, signs and cones used at RTCs,Recognise the safety procedures necessary when attending RTCsIdentify the considerations when making an appraisal and determiningpriorities in an RTC.

The training module links to the National Occupational Standards on personaland organisational development for firefighting hazards and risks inoperational incidents, and key skill units FF3 ‘Save and preserve endangeredlife’. It is also linked to Integrated Personal Development System unit 057‘Dealing with transport incidents’.

The training module provides detailed information on the approach andattendance to RTCs on motorways and dual carriageways. It gives guidance onpositioning of appliances, and illustrates the positioning of fire appliancesprior to the arrival of the police for incidents in lanes one, two or three ofcarriageways.

In addition, the training module provides motorway guidance when theincident involves:

Lane two and the hard shoulder is clear When the incident covers lane two and the hard shoulder is obstructedFor incidents in lane three, or for incidents covering lanes two and three.

5 Training and Competence

5.1


48

The training module also provides guidance on safety provision including thesafety of crews, ensuring they have the appropriate PPE and additionalprotective clothing including high visibility surcoats.

In order to ascertain the level of competence and experience with regard toworking on roadways the training records of those crew members whoattended Incident 10644 were examined. Their training is organised bothcentrally by the HFRS Training and Development Centre and locally, by thestation management.

The following is a summary of the central training and promotion historyrelating to the crews attending the incident.

SubO Paul Mallaghan

Joined the Service 07.01.91 Was promoted to Leading Firefighter 01.08.00 and to Sub Officer 01.09.01

He attended the following courses:RTA course 27.02.95Crew Managers Incident Command course 21.06.00Fire Service College for Crew Managers (Leading Firefighter) course 03.12.01 to 21.12.01RTC course 28.09.05

LFf

Joined the Service 17.04.01 Was promoted to Leading Firefighter 30.04.07 He has held LGV since 27.11.03

He attended the following courses:BA/RTA course on 23.10.03CMMI course from 30.10.06 to 10.11.06

KEY LFf Leading Firefighter also known as Crew Manager SubO Sub Officer also known as Watch Manager RTC Road Traffic Collision (previously RTA = Road Traffic Accident) BA Breathing Apparatus CMMI Crew Managers Managing Incidents DCT Driver Continuation Training LGV Light Goods Vehicle

1

49

Ff

Joined the Service 11.03.02 He has held LGV since 28.08.06

He attended the following courses:BA/RTA course 01.10.02 DCT course 02.02.07

Ff

Joined the Service 04.01.93

He attended the following courses:RTA course 22.02.95 BA/RTA course 22.04.03.

LFf

Joined the Service 21.08.00 Was promoted to Leading Firefighter 01.07.04 He has held LGV since 14.11.02

He attended the following courses:BA/RTA course 22.04.03 RTC course 28.09.05 CMMI course 29.01.07 to 02.02.07.

Ff

Joined the Service 17.11.97 Held an LGV since prior to joining Service.

He attended the following courses:DCT course 16.09.02 to 19.09.02BA/RTA course 01.10.02RTC course 28.09.05

Ff


She undertook her trainee firefighter course at the Training and DevelopmentCentre at Longfield, Stevenage. She joined Blue Watch in April 2007.

Ff


He has a range of experience and completed a course for ‘Basic Life Support and Automatic Electronic De-fibrillation’ (BLS/AED) 16/07/04 and qualified as an AED instructor on 30/08/05

1

2

2

3

4

5


50

Central Training

Below is a table summarising the crews’ central training records which arerelevant to working at this incident.

The CMMI course includes a training module specifically training newlypromoted junior officers on incidents on the roadway including safetymeasures when operating on roadways as follows:

Fire and Rescue Services Act 2004Fend offConingMotorwaysPolice ‘slow’ signs

First Aid

Some of the crew were involved in immediate casualty care and this is thesummary of their relevant training.

5.2

Name RTC course BA/RTA CMMI Recruit

P. Mallaghan 28.09.05 01.10.02 23.10.03 10.11.06 22.04.03

28.09.05 02.02.07 28.09.05 2007

2001

Name Immediate casualty care

23/11/04

01/11/06

01/11/06

01/11/06

01/11/06

04/04/07

01/11/06

L/Ff 1

L/Ff 1Ff 1

Ff 1

L/Ff 2

L/Ff 2

Ff 2

Ff 2

Ff 3

Ff 3

Ff 4

Ff 4

Ff 5

Ff 5

51

Station Based Training

The interim recording system for station based training was introduced on 16May 2005 and instructions were issued on Station Memorandum 62/05. Therecommended training frequency for all skills or competencies is ‘at leastonce in every three month period’.

The training records provided for April, May and June of 2007 were incorrectlydated. The year shown on the HFRS 52 was 2006. The correct date has beenverified by LFf and the hard copy in the training file has been re-dated and initialled.

The table below shows station based training recorded, relating to roadways.Records considered were January 2006 to June 2007. Only the most recentdate that training occurred is shown. There are further tables showingtraining in the use of equipment relating to road traffic collisions and firstaid/trauma care.

is a newly qualified firefighter from the Training andDevelopment Centre who joined the Watch in April 2007 and covered thebasics of RTC training during her Trainee Firefighter training. This includedvehicle safety systems; injuries; cuts on cars; fending off and coning off; RoadTraffic Act and Fire Services Act etc.

5.3

Traffic Law Siting Siting Fend Off Fend OffName Theory Theory Practical Theory Practical

P. Mallaghan March 07 March 07 March 07

March 07 March 07 March 07 March 07 April 07

March 07 March 07 June 07 March 07 March 07


March 07 March 07 March 07


March 07 March 07 March 07

L/Ff 1Ff 1

2

L/Ff 2Ff 2

Ff 3

FF 4

Ff 4

Ff 5


52

Use of equipment relating to Road Traffic Collisions

First Aid and Trauma Care

In conclusion, all members of the crew were suitably trained and experiencedin working safely on roadways and dealing with casualties.

Name Lukas Air mats Stabilisation

06/07 06/07

05/07 01/07 05/07

06/07 01/06 06/07

06/07 01/07 06/07

06/07 01/07 06/07

06/07 06/07

06/07 01/07 06/07

Bag Valve Name Mask/MARS De-fib CPR Casualty care

06/07 06/07 06/07 06/07

11/06 11/06 11/06 03/07

11/06 11/06 11/06 11/06

11/06 11/06 11/06 11/06

11/06 11/06 11/06 11/06

11/06 11/06 11/06 06/07

L/Ff 1

L/Ff 1Ff 1

Ff 1

L/Ff 2

L/Ff 2

Ff 2

Ff 2

Ff 3

Ff 3

Ff 4

Ff 4

Ff 5

Ff 5

53

Between 2000 and 2004 accidents on the hard shoulder claimed the lives of 67people and injured a total of 950 people. Although there has been no report ofany other Fire Service personnel being killed on the motorway in recent yearswhile responding to an incident in the UK, it is widely accepted that fastmoving traffic on a motorway poses a serious danger.

Although there is clear and comprehensive guidance for fire crews working onmotorway carriageways, there appears to be no specific operationalprocedures for Fire Service vehicles working on a hard shoulder. It should alsobe noted that the Fire Service Generic Risk Assessment 4.1. IncidentsInvolving Transport Systems – Roads was issued prior to arrangements beingput into place for the Highways Agency to manage the road network.

HFRS Service Policies and Procedures reflect the National Guidance forprocedures to be adopted on the motorway. The current SIS also providesconcise guidance on motorway procedures and the associated dangers.However, this SIS does not mention detailed illustrated guidance on fend offand coning procedures.

National guidance from the Fire and Rescue Service Manual (Volume 2)provides direction on the safest approach to take to incidents on themotorway, and how to fend off if an incident occurs within the carriageway. Itdoes not however give explicit guidance on incidents that may occur oncarriageways that merge with or lead to motorways or provide explicitprocedures for incidents on hard shoulders.

Many calls to car fires on the motorway tend to be either of a minor nature or false alarms. Due to the potential traffic disruption caused by a lane closure, fire crews will assess the nature of the call prior to deciding on any lane closures. If the vehicle is on the hard shoulder and fully involved in fire, the Fire Service may need to shut down both the hard shoulder and at least lane one to protect the firefighters working. The Incident Commander will risk assess and make decisions based on the scene.

Guidance from the Fire and Rescue Service Manual (Volume 2) states that when the fire service attend a working Road Traffic Collision ( RTC ) at any location including motorways, it is expected that an action circle extending outwards for 2 – 5 metres in every direction will be put in place. This circle provides a 360 degree view of the scene and saves valuable time byallowing fire service personnel to develop an adequate plan while operatingsafely. It therefore follows that an RTC on the motorway (including the hardshoulder) will result in the closure of more than one lane. There is clear national and HFRS guidance on lane closures and coning procedures in this instance.

6 Findings1

2

3

4


54

However, for the fire service attending a vehicle fire on the hard shoulder,there is no clear fire service guidance and therefore the Incident Commanderwill be expected to make a decision based on their dynamic risk assessmentin the absence of either the police of Highways Agency being in attendance.This will result in variations of operational practices nationally and locally.

The Guidance on Policing Motorways 2006 Manual (GPMM) advises that whena vehicle is on fire the police should close lane one when the burning vehicleis on the hard shoulder so that the Fire and Rescue Service can carry outtheir duties. There is no reference to this in The Fire and Rescue ServiceManual Volume 2, entitled Fire Service Operations – Incidents InvolvingRescue From Road Vehicles.

HFRS has a good relationship with the Highways Agency and is signed up to aRegional Memorandum of Understanding. On the introduction of theHighways Agency into Hertfordshire in 2004, a clear process was introducedinto the Fire and Rescue Service to ensure that all information available wasdisseminated to personnel by Station Memorandum and by the use of theHFRS local intranet. At top level management there is a clear link betweenthe Highways agency and HFRS. However, HFRS does not have a clearprocess for communicating information to operational personnel.

All national guidance indicates that it is the responsibility of the police inconjunction with the HATOs to provide a safe working area for otheremergency services when they are in attendance.

The Fire and Rescue Service will be guided at an incident by the police orHATOs on parking of emergency vehicles on the motorway when they are inattendance.

HFRS Command and Control were unaware of the ability they have to requestHighways Agency to set matrix signs to control the speed of approachingtraffic prior to the HATOs arriving.

The investigation shows that Incident Commander and crews appear to havefollowed HFRS Standard Operating Procedures at this incident.

It is almost certain that the Incident Commander SubO Paul Mallaghan hadremoved his fire helmet as he attempted to view the damage to the Saab. Hewas carrying his fire helmet in his hand at the time of the collision. LFf

was not wearing his fire helmet or gloves because he had taken themoff to speak with the driver of the Saab and this directly led to him receivingserious head injuries. However, all fire crews in both 230 and 231 fireappliances were rigged in the appropriate PPE clothing for an incident of thisnature to ensure high conspicuity and were complying with the appropriatestandards.

5

6

7

8

9

10

11

1

55

The HFRS waistcoat style hi-vis jacket is rated to class 2 but fulfils therequirement of class 3 retroflective material at operational incidents on dualcarriageways with speed limits above 50mph. Class 2 is the lesser standardand is suitable when it is worn in conjunction with the fire tunic.

Although compliant with the appropriate standards, it appears that HFRSIncident Commanders wear a lesser standard of surcoat in a white or whiteand yellow version in accordance with the correct Incident Command Systemas they would not normally be required to direct traffic and would work withina ‘protected zone’.

The fire appliance in attendance at the time of the collision (i.e. 230;registration was a spare vehicle which was being used byStevenage whilst their substantive fire appliance was being serviced. Thespare vehicle meets all the minimum legal standards for lighting andconspicuity markings relating to emergency vehicles. The police inspectedthe vehicle at the scene on the night of 16 June 2007 during their CrashInvestigation and found it to be in working order and compliant with therequirements for working on the roadway.

The ‘In Line’ fend off position on the hard shoulder of the slip road deployedby the HATO vehicle at this incident provided limited protection from vehiclestravelling south bound on the main carriageway of the motorway. Its aim wasto provide a physical barrier from vehicles travelling down the slip road andprovide a visible presence for on-coming traffic. There are differences in thechoice of ‘fend off’ positioning between the Police, Highways Agency and FireService due to varying responsibilities and operating procedures. On thisoccasion both the Highways Agency and HFRS were fending off in accordancewith their current standard operation procedures.

The Service meets the statutory requirements in relation to conspicuity andworking on highways and roadways, in terms of personal protective clothing,vehicle markings and lighting.

The range of training undertaken by the Stevenage crews who attended thisincident shows that there were adequate and appropriate levels of experienceand knowledge to enable them to deal with an incident on the roadway whichdeveloped from a small car fire to a multi-vehicle collision involving severalcasualties.

12

13

14

15

16

Reg Removed


56

57

7 RecommendationsSpecific operational procedures for fire service vehicles working on a hardshoulder need to be drawn up. These need to incorporate the guidanceoffered from the ACPO Guidance on Policing Motorways 2006. The FireService Generic Risk Assessment 4.1 Incidents Involving Transport Systems –Roads needs to be revised and updated.

No cones or warning signage were deployed by the Fire Service at thisincident because the Highways Agency were in attendance and would takeresponsibility for this task if it was felt necessary. However, the HFRS SISOPS 2/30 Incidents Involving Road Vehicles does not mention detailedillustrated guidance on fend off and coning procedures. The SIS needs to takeinto consideration the Highways Agency role, the Police role and the incidentlocation – which on this occasion was on the hard shoulder.

The Fire and Rescue Service Manual (Volume 2) needs to have explicitguidance on incidents that may occur on carriageways that merge with, orlead to motorways.

When attending a vehicle fire on the hard shoulder, there is no clear fireservice guidance and therefore the Incident Commander will be expected tomake a decision based on their dynamic risk assessment. This could result invariations of operational practices. It is recommended that a definedprocedure for all operational activity on the hard shoulder is designed andimplemented.

The Guidance on Policing Motorways 2006 Manual (GPMM) advises that whena vehicle is on fire the police should close lane one when the burning vehicleis on the hard shoulder so that the Fire and Rescue Service can carry out theirduties. This working practice needs to be consolidated and introduced intoHFRS and national standard operating procedures.

There is no reference to point 5 above in The Fire and Rescue Service ManualVolume 2, entitled Fire Service Operations – Incidents Involving Rescue FromRoad Vehicles. This needs to be addressed.

HFRS has a good relationship with the Highways Agency and is signed up to aRegional Memorandum of Understanding (MOU). However, a clear process forcommunicating the MOU to operational personnel is required in order tomaintain operational efficiency across the different agencies.

The Highways Agency has invited Command and Control staff to visit theirControl Centre in South Mimms and this offer should be taken up for all ofCommand and Control personnel in order to improve cross-agency workingand knowledge of procedures and systems.

1

2

3

4

5

6

7

8


58

In addition there should be formalised procedures put in place to ensure allCommand and Control staff are aware that they can contact HighwaysAgency Control to request matrix signs are ‘set’ for incidents on roadways,(this would be at 50mph until a HATO or police officer instructs themfurther).

All high visibility jackets worn were adequate, appropriate and fit for purposebut it is recommended the standard issue should be consistent across allranks in HFRS.

High visibility clothing and all Personal Protective Equipment including headprotection must be worn whilst working on any part of a highway.Operational personnel need to be reminded of this requirement.

Statistically more accidents and near misses occur during the closing stagesof an incident than at any other time. Personnel need to be reminded tocontinue to be vigilant and alert at the closing stages of an incident.

The Fire and Rescue Service are increasingly being called to vehicle fires andalso need to be aware of the different types of fuel that could be involved(gas, diesel etc) and the control measures required to deal with theseincidents. This information must be included in the appropriate SIS.

The Fire and Rescue Service should seek to promote and participate in anactive national campaign to raise the public awareness of the dangersassociated with stopping on the hard shoulder of motorways and roadways.

9

10

11

12

13

14

59

ACPO – Guidance on Policing Motorways 2006 Manual (GPMM)Traffic Management Act 2004

Essex Fire and Rescue HSE Improvement Notice

Fire Service Manual volume 2

Manual of Firemanship Book 12

Generic Risk Assessment 4.1 – Incidents Involving Transport Systems - RoadsDCOL 4/1991 Fire Service Procedures for Incidents on Motorways

DCOL 8/1997 the Road Vehicles (Construction and Use) (Amendment)

Regulations 1997

DCOL 9/1994 Attendance at road Accidents

DCOL 6/1992

DCOL 13/1982 Hazards from Vehicle Fires

DCOL 8/1994

DCOL 4/1991 Fire Service Procedures for Incidents on Motorways

HSE SIM 7/2005/16

Hard shoulder Accidents 2005 (Highways Agency)

Hard Shoulder Safety Systems PRSE 62302

Highways Agency SOP

HFRS SIS 2/030 – Incidents Involving Road Vehicles June 2004ACPO Road Death Investigation Manual 2001

Personal Protective Equipment at Work Regulations 1992

Unsafe Stopping – The AA Motoring Trust

Regional MOU between Highways Agency/Fire and Rescue Service East

Region

Cambridgeshire FRS: Operational Technical Order: Special Services: Road

Traffic Accidents

Cambridgeshire FRS: Hazard Warning Bulletin: Coning Off Procedures

Cambridgeshire FRS: Motorway/Dual Carriageway Coning off Procedure

HM Fire Services Inspectorate: Significant Safety Event No. 9: Coning at

motorway/dual carriageway incidents

Essex Fire and Rescue Service – Service Information System – Motorway andDual Carriageway Procedures

8 Reference Documentsand Bibliography


60

61

9 Appendix 1Plans showing staged vehicle positions up toand including the collision.


62

Fig. i At 21.25.47: 231, Saab, 230, and “second vehicle” approx. 100m along hard

Representation only of thepositions of 231, the Saab,230 and the “secondvehicle.”

63

Fig. ii At 21.29.01: Highways Agency, Saab, 230 and “second vehicle”

Representation only of thepositions of the HighwaysAgency Vehicle, the Saab,230 and the “secondvehicle.”


64

Fig. iii At 21.35.24: Highways Agency, estimated line of travel of VW Golf, Saab shuntedapprox 15m, 230

Representation only of thepositions of the HighwaysAgency Vehicle, the Saab,230, the Golf and the“second vehicle.”

65

Fig. iv Post-collision At 21.40.30: Highways Agency, 231 returned, VW Golf, Saab, 230

Representation only of thepositions of the HighwaysAgency Vehicle, 231 (returnedto incident) the Golf, 230, andthe Saab, post collision.


66

67

9 Appendix 2Glossary of Fire Service Terms


68

CFO Chief Fire Officer

DCFO Deputy Chief Fire Officer

ACO Assistant Chief Fire Officer

DO Divisional Officer

StnO Station Officer - also known as Station Manager

SubO Sub Officer - also now known as Watch Manager

LFf Leading Firefighter - also now known as Crew Manager

Ff Firefighter

CREW A collection of firefighters – can be of differing ranks and havedifferent tasks assigned, but will usually be from one fire engine.

IC Incident Commander – in charge of the entire incident

OIC Officer in Charge – the person in charge of an appliance/crew

CONTROL Fire Service Command and Control Centre where all the telephone calls, radio messages and mobile phone calls are received.

CU Mobile Control Unit (also known as: CCU or CSU)

RSU Rescue Support Unit

Messages and LanguageTM Tactical Mode

TM OSCAR Tactical Mode Offensive – in operational terms

TM DELTA Tactical Mode Defensive – in operational terms

MAKE PUMPS... A request that further fire appliances are required. (With 2 pumps in attendance, ‘make pumps four’ is a request for two additional appliances, totalling 4).

RTC Road Traffic Collision (formerly RTA: Road Traffic Accident)

CODE Details the condition of the person/s involved in the incidentCode 1 = FatalCode 2 = Injured; casualty referred to hospitalCode 3 = First aid only; precautionary checkCode 4 = Involved but not injured

FDR1 Fire Damage Report 1 form completed for every fire

INFORMATIVE a message to Control detailing current status of the incident

MOBILE A fire appliance is responding to the call and is on the way to the incident

69

STOP Message to Control indicating no further resources required at the incident

Firefighting Equipment and OperationsPUMP/WAGGON/ Fire Appliances/engines referred to by the station call-MOTOR/LORRY signs. ‘2 3 0 (two three zero)’ or ‘2 3 1 (two three one)’.

The first pump from Stevenage station is 230 the second pump is 231.

FIRE KIT Personal protective clothing comprising fire helmet, fire hood, tunic, leggings (overtrousers), boots, gloves.

HAT/HELMET Head protection

SURCOAT A sleeveless waistcoat style over-jacket usually high visibility colour worn over a fire tunic.

IN-LINE The emergency vehicle (police car, Highways vehicle, fire engine) is parallel to the running lanes of a carriageway

FEND OFF In Fire Service terminology this means that a vehicle is positioned at an angle – usually 45 degrees – on the high risk side of an incident pointing the traffic in the direction it should pass.

‘RIGGING EN Attempting to dress in fire kit and/or BA whilst ROUTE’ the fire engine is moving. This is prohibited by

the Service.

BA Breathing Apparatus

BA Team Comprises a minimum of two breathing apparatus wearers.

No1/No2 Breathing apparatus team members role – BA 1 is the ‘leader’ This is also indicated in their ‘positions’ on the fire engine i.e. where people sit indicates their role.

BA Set Breathing Apparatus Set – comprising air cylinder, harness, face mask and ancillary equipment.

RIGGING IN BA Putting the BA set on your back and adjusting the fittings.

START UP Going through the start up procedure – turning on the air, ensuring the face mask fits and taking the first in-breath of air.

UNDER AIR A firefighter is breathing air from the BA cylinder


70

HOSE REEL Small bore (19mm size) hose supplied from high pressure outlet of the fire engine

LENGTH A length of hose measured in meters but also in millimetre diameter – i.e. a length of ‘45’.

BRANCH Attached to the end of the hose. Used to direct the water and adjust the spray – a lever is pulled back to ‘open’/operate it.

CHARGED There is water in the length of hose.

LUKAS, COMBI- Range of specialist equipment for use with RTCs.TOOL, POWER PACK, RAM SUPPORT

CHOCKS/BLOCKS Wooden and hardened blocks used to stabilise vehicles.

AIR MATS Expanded under pressure and used to lift vehicles.

MARS, Equipment which supplies oxygen to a casualty.BAG VALVE MASK

COMMS Communication

RADIOS/COMMS Hand-held radios – for use by firefighters on the fireground.Main scheme – on the fire engine only.Mobiles – on all fire appliances and every officer is issued with a Service mobile phone.

71

9 Appendix 3Appliances and Crews attending Call 1064416th June 2007


72

230 Stevenage 1st Pump

OIC SubO Paul MallaghanDVR Ff BA1 LFf BA 2 Ff

231 Stevenage 2nd Pump

OIC LFf DVR Ff BA 1 Ff BA 2 Ff

320 Hitchin 1st Pump

OIC SubO DVR Ff BA 1 Ff BA 2 Ff

LFf

321 Hitchin 2nd Pump

OIC SubO DVR Ff BA Ff

185 Hatfield Rescue Support Unit

OIC LFf DVR Ff

310 Baldock & Letchworth 1st Pump

OIC SubO DVR Ff BA 1 LFf BA 2 Ff

11

22

34

5

16783

49

1011

3126

13

2

73

OFFICERS Call Sign

CFO B1

DCFO B2

ACO B3

StnO SM2

DO G10

StnO SM9

StnO SM5

StnO SM23

StnO SM11

DO G6

StnO SM14

DO A3

StnO SM3

COMMAND AND CONTROL

16 June 2007

17 June 2007

1

22

2

11

3456

3

47

CS 1CS 2CS 3CS 4

CS 5CS 6CS 7CS 8


74

75

9 Appendix 4Sequential Timed Event Plotting Information


76

Time Event Evidence

999 Mobile phone call to Control: Car Fire Diesel Special Service Junc 8 7 MW A1(M)

Control Log230424

21.16.36

21.17.44 230 Stevenage Alerted to incident

21.17.53 231 Stevenage Alerted to incident

21.19.12 Agency Police informed Police log 1266Control Log 230426

21.20.02 231 Mobile – (northbound unaffected carriageway) 7-8 LFf – Crew of 4

Control log 3723396

As 231 approaching from northbound carriageway LFf radios there are 2 cars on the motorway.Ff says 231 said there is no sign of any fire northbound.

LFf LFf Ff & Ff contemp. notes.

21.24.58 230 In Attendance

Receive message from 231 too late to park behind Saab so park between cars in front of Saab.Ff says as they head up slip road the car at the top didn’t appear to be on fire. There is a second car with hazards and people.Ff (driver) parks “6 lengths” from Saab with blue lights on. Ff estimates 15m from rear of 230 to fire car.2nd vehicle/car in front has hazards on. This was estimated to be located approx. 100 metres further down the hard shoulder in front of 230.

Control Log 3723400

Ff Jennings & Ff WilliamsContemp. Notes.

DO Hardy’s notes.

LFf states that when parked we can see the second vehicle (SAAB) was the vehicle on fire. Small fire under bonnet, mainly steam plus oil dripping from bottom.

LFf contemp. note.

21.20.24 230 Mobile – (southbound affected carriageway) 8-7SubO Mallaghan – Crew of 4

Control log 3723397

Ff asks SubO Mallaghan if cones are wanted and he says Highways Agency will do that.

Ff contemp. note.

Ff & LFf get off. Ff gets BA set off nearside whilst LFf

and SubO Mallaghan proceed to vehicle on fire. Ff then got hose reel off and took this to the vehicle on fire.

Ff contemp note.

21.53.33

KEYSignificantevent

Fire Serviceattendance

Non FireServiceactivity

Boldtype

Key informativeor other keyinformation

1

1 1

1

1

1 1

1

1

1 1

2

22

5

5

55

5

5

77

Time Event Evidence

Ff gets fire kit off and wears hi-viz because he says “traffic is heavy”. Stands at pump bay acting as Safety Officer.

Ff contemp. note.

SubO Mallaghan speaks to owner of Saab. LFf contemp note.

Ff & LFf are at the Saab with hose reel and BA; LFf pops bonnet; Ff extinguishes fire fairly quickly.

LFf contemp. note.

LFf sees Highways Agency approach on northbound carriageway.

LFf contemp. note.

LFf asks Paul if he wants him to get FDR1 (fire report) information.

21.25.47 231 In Attendance

Parks in the fend off position (45º angle) across the hard shoulder and the end of the on slip of jct 8 behind the Saab. LFf Radios SubO Mallaghan to ask if he needs assistance and Paul replies no.

Control Log 3723401

LFf &ff contemp. notes.

Ff looks into his off-side mirror and sees the HA coming up the slip of Jct 8 southbound.

Ff contemp. notes.

Ff doesn’t know where the HA vehicle was.

Ff contemp note.

LFf contemp note.

LFf goes to rear of 230 where owner is stood. takes off helmet and gloves to talk and write information.

LFf contemp. note.

Whilst LFf does this SubO Mallaghan radios LFf and tells him “the Highways Agency are here you might as well get yourself away and they can move into your position”.

LFf & Ff contemp note.

21.28.58 Highways Agency Vehicle arrives – crewed by 2 personnel: 1 female 1 male

Highways Log

21.29.01 231 Status changed from In Attendance to Mobile Return

Control log 3723404

Highways Agency Officer speaks to SubO Mallaghan and states they would get car moved when cool.

Ff contemp note.

21.53.33

KEYSignificantevent



Boldtype


1

11

1

1 1

1 1

1 1

1 1

2

2 2

2

2

2

2 2

2

55

5 5

L/FF 1

5

L/FF 1

HA 1


78

Time Event Evidence

Ff asks SubO Mallaghan if cones are needed and SubO Mallaghan tells him that Highways will do that.

Ff contemp note.

LFf walks towards the rear of the Saab where Highways Agency are now and introduces owner of car.

LFf contemp note.

The owner and the HA Officer stand behind the barrier now.

Highways Agency Hot-debrief

21.30.23

Ff and Ff get out of 230. Ff & Ff contemp. notes.

LFf walks back towards 230.Ff is restowing BA in 230.SubO Mallaghan is now standing at the front of the Saab looking at the damage “assume to work out what happened for FDR1.”

LFf contemp. notes

SubO Mallaghan points to the engine block and says “it’s something down there.” moves towards the front of the Saab to talk/look at what Paul was doing.

LFf contemp. notes.


Highways Log

21.29.01 LFf says there is a sudden bang/massive noise and he sees “black/light/black/light.”Ff was getting kit together when he heard a “quiet bang” and said to Adam “what was that?” and something went past the appliance.Ff was in the OiC seat going to send STOP message when he heard a noise in the cab and looked in the mirror.

LFf Ff & Ff contemp. notes

Ff saw a firefighter on the hard shoulder where the fire vehicle originally was; he saw different car on the motorway; he got to LFf – spoke to him, confirmed he was OK. Scanned scene looking for SubO Mallaghan. Went past new vehicle involved and he didn’t realise initial fire vehicle was right behind 230.

Ff contemp. note.

230 Informative sent by Ff Sub O Mallaghan small fire in engine compartment 1BA 1HR in use TM OscarFf tells SubO Mallaghan message is sent.

Control Log 3723405/404

21.53.33

KEYSignificantevent



Boldtype


1 1

1 1

1

1 1

1

1 1

11

1

1

1

1

5 5

5

55

5

HA 1

L/Ff 1

5

79

Time Event Evidence

Ff sees the vehicle on fire has been shunted into lane one. Ff goes to SubO Mallaghan. He was not responding and he is “obviously in a bad way”.The driver of the vehicle is in shock but uninjured. Ff sent him to wait with ‘the vehicle’.Driver of 2nd vehicle now facing the wrong way up the motorway remained in car.

Ff contemp. note.

LFf is laying in the road, confused, blood/fluid running down his face. Moves his left arm and felt the curb and moved half on that for safety.LFf sees Ff and Ff get out of 230.

LFf contemp. note.

SubO Mallaghan is under the Saab car. LFf Ff and

contemp. note

One Highways Agency crew is injured and has fallen backwards over the barrier when LFf was thrown into him. He had been speaking to the driver of the Saab who was the other side of the barrier.

StnO Contemp notesHighways Agency info.

Highways Log

LFf Crook, Ff Williams & Ff Jennings contemp. notesFf goes back to appliance to send

messageFf contemp note.

230 Informative: Collision on A1 Make pumps 2 ambulances required RTC involving appliance person trapped

Sent by Ff Control Log:3723407 37234093273410,

21.35.24

21.35.38 231 Status changed from Mobile Return to Assigned

Control log 372407/372410

Ff speaks to the owner of the Saab who is now standing next to the appliance and tells him to wait with the ‘unknown’ vehicle which is further down the carriageway south of the incident.

Ff response.

The Highways Agency Traffic Officer sends an assistance message via handset radio to Highways Agency Control that ‘fire engine been hit - people injured – whole carriageway closed’.

Highways Log21.35.42

Ff asks Highways to fend off as much of motorway as possible.

Ff contemp. note.

Highways Agency Officer instructs driver of a vehicle now stopped in lane 2 to remain there.

Ff contemp. note.Highways Agency Hotdebrief

21.53.33

KEYSignificantevent



Boldtype

Key informativeor other keyinformation 1

1

1

1

1

1

1

1

1

1

1

1 1

1

1 1

1

5

5

5

HA 2 1

HA 1

HA 1

5


80

Time Event Evidence

Highways Agency ring Control: request fire engine to junction 7 to 8 northbound carriageway as they state there has been a further incident. Believe one of our pumps struck: HFRS Control Op. confirms operating on southbound between 8 to 7 already.

Control Log 230429HA reference RD1600 16.6.07

320 Hitchin Alerted

Ff gets RTA kit off – Lukas/power pack, ram support.

Ff gives a bandage: LFf tells him he is OK and to go and help Ff with Paul; Ff checked on driver of crash vehicle 2 (Golf); Ff goes to the Highways Officers who are standing together next to the crash barrier and they confirm they are OK and tell him to help his colleagues, then assists Ff with Paul.

Ff &LFf contemp. note.Ff response.


Highways Log

21.29.01 LFf Crook says there is a sudden bang/massive noise and he sees black/light/black/light.Ff Williams was getting kit together when he heard a “quiet bang” and said to Adam “what was that?” and something went past the appliance.Ff Jennings was in the OiC seat going to send STOP message when he heard a noise in the cab and looked in the mirror.

LFf Crook, Ff Williams & Ff Jennings contemp. notes

Ff gets spreaders off appliance.

StnO Mobile21.37.55

21.38.39 Ambulance Informed Ref 1814198 Control Log 230432

The Highways Agency calls Fire Control to advise re accident on the A1(M) – one vehicle is smoking and says a second unit may be required. Fire Control confirms that they have 2 on way.

Highways Agency Log & Fire Control Log 230434

21.39.44

320 Hitchin Mobile to incident – OIC Sub O Crew of 5

Control Log 3723414

An off-duty paramedic who was stuck in the traffic assists with SubO Mallaghan and advises Ff

that SubO Mallaghan needed getting out.

Ff put spreaders under near side front wheel and lifted vehicle sufficiently for paramedic to commence CPR.

Ff thinks that 230 is too close so gets into it and moves it forward about 8 feet.

Ff & Ff contemp. notes.

21.35.50

21.35.57

21.37.01 StnO alerted

21.37.27 Highways Agency Officer sends a message: ‘2 firemen – 1 HATO and 1 other person injured – vehicle smoking’.

Highways LogHighways Hot Debrief

21.38.41 231 Mobile to incident

21.39.54

21.53.33

KEYSignificantevent



Boldtype


11

11

1

1

1

1

1

2

2

5

5

5

5

5

5

1

L/Ff 1

1

81

Time Event Evidence

LFf can see Ff & Ff had set the Lukas up and using the spreaders under the sill to lift the Saab off Paul.

LFf contemp. note.

DO assigned

Ff dismounts and sees the Golf in lane one/two has a quick look in the vehicle and could see the driver upright and calling out. He then goes to LFf on the hard shoulder.

21.42.01 231 Informative Priority (LFf - Make Pumps 4

Control Log: 3723416LFf contemp. note.

21.29.01 LFf Crook says there is a sudden bang/massive noise and he sees black/light/black/light.Ff Williams was getting kit together when he heard a “quiet bang” and said to Adam “what was that?” and something went past the appliance.Ff Jennings was in the OiC seat going to send STOP message when he heard a noise in the cab and looked in the mirror.


Ff then sees SubO Mallaghan under the front of the Saab and that he is trapped, and was not breathing.Ff assists an off-duty paramedic with CPR.

21.40.23 Police Informed

Ff goes to LFf and he tells her that SubO Mallaghan is under the car. She sees Ff

and a London paramedic working on SubO Mallaghan and goes to assist by providing oxygen.

Ff contemp. Note.

Ff makes a mobile phone call from 231 to Control (FCO stating “got 2 firemen down on the roadway - need ambulance and old Bill.” FCO confirms StnO and Hitchin are on their way.

Control log 230436

21.40.14

LFf is aware of 231 arriving as Ff comes up to LFf and gives him a bandage to put on his head. Ff leaves LFf to help with SubO Mallaghan.

21.40.30 231 In attendance

LFf got off appliance and sees a firefighter laying on the ground – LFf – with a bandage to his head and he says he’s OK that Paul needs attention.LFf goes to SubO Mallaghan and he has an ambulance woman working on him.

LFf contemp. note.

Ff contemp. note.

LFf contemp. note.

Ff contemp. note.

LFf goes over to Ff and Ff informs him that Paul is in a bad way and they need to get him out fast. The rest of the crew continue to stabilise the vehicle and place air mats whilst Ff works on SubO Mallaghan. SubO Mallaghan initially begins breathing for himself but stops.

Ff contemp note.

21.53.33

KEYSignificantevent



Boldtype


1 1

1

1

1

11

1

1

1

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3 3

3

3

4

5

CS 2

CS 2

4


82

Time Event Evidence

LFf gets crews to provide more blocks and he checks the driver of other collision vehicle who complains of pains to his chest but appears OK so LFf leaves him.

LFf contemp. note.

321 Hitchin (2nd pump) Alerted

21.42.42 StnO Informative: Request DO attendance

Control Log 3723416 21.29.01 LFf Crook says there is a sudden bang/massive

noise and he sees black/light/black/light.Ff Williams was getting kit together when he heard a “quiet bang” and said to Adam “what was that?” and something went past the appliance.Ff Jennings was in the OiC seat going to send STOP message when he heard a noise in the cab and looked in the mirror.


21.42.16 StnO in attendance

Ff is briefed by LFf and he puts him in charge of scene lighting. Ff sees that SubO Mallaghan is being attended to by 2 ambulance personnel and efforts are being made to raise the vehicle. He ascertains that is conscious.

LFf sees Hitchin approaching so radios them for their air mats.

LFf contemp note.

Ff returns to LFf and applies a second dressing to his head wound, quickly assessing his injuries.Whilst dealing with him he notices the driver of the other vehicle is now slumped over his steering wheel so Ff goes to the vehicle, opens the door and raises his head.

21.40.30 231 In attendance

Ff contemp note.

310 Baldock & Letchworth Alerted

LFf contemp note.

21.42.17

21.43.01 231 Informative: RSU Required sent by Ff

Control Log 3723419

21.43.22 185 (Hatfield RSU) Alerted Control Log 3723419Ff gets power pack and combi tool off 231. Ff

contemp. Note.

21.43.40 DO informed Control Log 3723419

21.43.52 321 Mobile to incident – OIC Crew of 3

Control Log 3723422

21.44.04

Mobile phone call from 321 at req of Control to advise of what they are going to: RTC 2 firefighters injured/trapped

Control Log 27955

21.44.41 320 Hitchin In attendance

StnO appoints SubO as Command Support Officer and 320 is made Control Point

Control Log 3723422

Hitchin crew Ff Ff & LFf provide blocks & airmats and assist Stevenage crew working to lift the Saab to release SubO Mallaghan.

21.53.33

KEYSignificantevent



Boldtype


1

2

2

2

2

2

2

2

2

2 2

2

2

2 2

3

3

3

5

5

1

7 8 3

SubO 2

L/Ff 1

83

Time Event Evidence

21.45.34 310 Baldock Mobile to incident SubO Crew of 4Advised to ring Control via mobile

Control Log 3723422/26

Ff checks on LFf and the driver of the Golf and then arranges lighting.

185 on way ring Control via mobile phone: advised attending incident involving 230 - a vehicle ploughed into it whilst dealing with car fire and 2 firefighters trapped.

Control log 230448

B3 ACO informed of incident

21.46.23 185 Hatfield Mobile to incident - OIC LFf 2 Riders

Control log 3723426

21.49.19 StnO Alerted

21.49.04 231 Informative LFf 2 cars in collision on MW 2 firefighters injured plus 1 civilian suffering from head injuries and trapped; Lukas airmats in use Stn Officer in charge.Make ambulance 3.

“ 231 – can I send an informative from LFf – 2 cars in collision on A1(M); 2 firefight-

ers injured; one firefighter suffering from head injuries and trapped under vehicle; Lukas air mats & everything else RTC wise in use; ….Hitchin is with us… now in charge of incident; make ambulances 3; confirm 2 firefighters and one civilian injured – apologise forgot that one”.

Control Log 230442 mobile phone call to Control byFf

21.49.55

21.50.16 321 Hitchin In attendance

StnO instructs SubO to stay with LFf and first aid is administered with assistance from Ff and LFf

Control log 3723434

310 SubO rings Control on mobile phone: confirms 8-7, advised by that they are going to 2 firefighters trapped

Control log 27952

21.46.33 Ambulance on scene Highways Agency Log

21.48.53 Two police units on scene Highways Agency Log

Ff contemp. note.

Ff is with the driver of the Golf. Ff contemp note.

21.50.23 G10 DO in attendance

DO sees the activity and that StnO is heavily involved in command and control so DO

liaises with the Police Inspector who appraises him of the situation.

Control log 3723434

21.51.32 G6 DO to attend Control

21.53.33

KEYSignificantevent



Boldtype


1

1

2

2

2

StnO 2

22

2

2

2

2

2

23

3

4

11

1

3

3

23

3

CS 3

2

2FF 2


84

Time Event Evidence

21.51.52 320 Informative Now Control Point Control log 3723437


Firefighters Ff from Hitchin and Baldock crews assist Stevenage crews Ff Ff in a variety of tasks including the release of SubO Mallaghan, first aid for LFf and the extrication of the driver of the VW Golf car.

StnO provides DO with a concise briefing and DO advises he is taking over Incident Command but advises StnO to continue to coordinate the rescue.

DO contemp note.

320 Informative: Further info – StnO – Details as previous – steady progress being made – Tactical Mode Oscar

LFf Scotchford contemp note.

22.01.43

185 calls Control via mobile: going to RTC involving 230 2 firefighters trapped;

21.53.33 Agency Ambulance Informed: Ambulance Information of Make Ambulances 3

Control Log230450

22.00.25

21.52.45 310 Baldock/Letchworth In attendanceBaldock receive a radio message from Ff

requesting their airmats urgently.

Control log 3723443

21.52.58 StnO Mobile Control log 3723445

Ff assists Ff who is attending the casualty in the VW Golf.

Ff contemp note.

Contemp notes.

ACO Assigned

LFf Ff &

contemp. notes.

21.58.59 185 Hatfield RSU In attendance

185 Control via mobile phone: Available at incident. advises colleagues from Toddington Heavy Rescue Tender, Beds send message they are available if needed.

Control log 230470From 185 via mobile phone

LFf and LFf assist LFf providing a stiff neck collar and oxygen mask and cut off his PPE. They work with the ambulance to get him on a spinal board and in to an ambulance.

Control log230448

Control Log 3723454

SubO Mallaghan is released from under the Saab and put on a spinal board, into an ambulance and conveyed to Lister Hospital.

StnO – Mobile to Incident22.01.35 Control Log 3723454

22.02.11 DO Mobile

22.03.54 StnO will be attending Stevenage Fire Station

22.02.44 DO In attendance at Command & Control

21.53.33

KEYSignificantevent



Boldtype


1

11

2

2

2

22

2

3

4 5

78

33

11

11 11

6

2

3

6

6

33

L/FF 6

CS 2

85

320 further to previous message: requires officer for incident investigation at the scene

Control log 27963 mobile phone call

22.16.18 StnO – In attendance

Time Event Evidence

22.05.15 231 Informative LFf DO now OIC 1 firefighter released and being taken to hospital by amb – 1 ff still trapped expected to be released soon – driver of other vehicle still trapped by injuries – ambulance still working

“ Paul has been released and is being taken to hospital; is shortly being taken to hospital now – he was not trapped; the car driver of other car is still inside the vehicle but is only trapped by his injuries not trapped mechanically ambulance is still working on him; nothing in use at the moment. …. he (Paul) was semi-conscious when he left (in answer to Control Op asking how he was)”

Control LogMobile phone call 230456 from LFf 231


21.40.30

StnO – Informative: Closing Stevenage Fire Station


Ff Ff Ff Ff Ff work to release the driver of the VW Golf. Ff coordinates with the ambulance until the driver is released and conveyed to hospital.

Control Log230450

22.13.26

Contemp. notes

22.13.43 ACO In Attendance

22.07.39 320 Sub O SM2 Informative Flexi duty officer required at C23 to liaise – Occ Health required to be informed (of 2 firefighters injured)

FCO advises DO at Control; StnO being collected: ACO sent StnO

to Stevenage; DO at Control. Cover in hand.

Control Log 27961 Mobile phone call to FCO due to nature of message

22.16.43 StnO (Station Manager Stevenage) In attendance at incident but off duty

22.19.47 320 Informative: From DO flexi duty to attend Lister Hospital

“also wants Flexi Officer at Stevenage forreturning crew and asks for Flexi duty officer for investigation of incidentAdvises Control of names of firefighters injured:

and Paul Mallaghan so there is no doubt.”

Control log 27962 mobile phone call to FCop

DO informing G4 DO 22.20.42

StnO Alerted22.24.17

StnO to attend Lister Hospital22.24.33

StnO Recalled to Duty22.24.55

21.53.33

KEYSignificantevent



Boldtype


L/Ff 1

L/Ff 1

11

2

2

2

2

34

1

7 8

10

11

2

23

5

5

6

6

3

3

7

CS 1

CS 2

CS 2

5


86

Time Event Evidence

STOP SIERRA 011 PERSONS CODE 1 3 PERSONS CODE 2

23.28.40

Highways Log

StnO re-directed to Control. StnO to attend Lister Hospital

22.26.47

StnO re-direction to incident for incident investigation

22.28.28

231 Mobile return22.28.37

DO to attend control – brief description on incident given

22.30.22

Police accident investigation is on scene22.53.29

DO in attendance at Control22.55.31

CFO informed22.33.52

DCO aware22.53.43

310 Not available – clear of incident23.05.46

StnO In attendance23.08.23

StnO Mobile to incident23.10.21

321 Home – clear of incident23.10.52

320 Home – clear of incident23.11.22

StnO to pick up CFO23.12.11

185 Home - clear of incident23.12.42

21.53.33

KEYSignificantevent



Boldtype


1

1

1

1

3

4

4

4

4

87

Control log 27963 mobile phone call

Time Event Evidence


21.42.16 StnO Harding in attendanceFf Williams is briefed by LFf Scotchford and he puts him in charge of scene lighting. Ff Williams sees that SubO Mallaghan is being attended to by 2 ambulance personnel and efforts are being made to raise the vehicle. He ascertains that Ian is conscious.

21.40.30

231 In attendance


21.53.33 Agency Ambulance Informed: Ambulance Information of Make Ambulances 3

Control Log230450

Control log 27962 mobile phone call to FCop Story

StnO in attendance at Stevenage FS with CFO

00.16.18

DO recalled to duty00.17.21

Occupational Health in communication with DO

00.22.52

DO recalled to duty00.32.30

DO In attendance 02.35.42

230 Not available – clear of incident00.48.00

DO available clear of incident03.23.39


17th June 2007

StnO In attendance01.47.15


DO Request 240 Hertford to come to incident to collect 230 pump

03.12.14

StnO available clear of incident03.32.22



ACO available clear of incident04.07.12StnO available clear of incident04.02.45


Duty officer at DCLG informed – will pass on at 09.00 to oncoming officer who may contact Control

08.52.38

Health & Safety informed – will liaise with ACO & will then inform HSE.

10.12.33

END

21.53.33

KEYSignificantevent



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1

12

2

2

H&S1

2

2

3

4

4

3

3

4

4

7

7

6

Hertfordshire Fire and Rescue ServiceService HeadquartersOld London RoadHertfordHertfordshireSG13 7LD.

www.hertsdirect.org/fire