Risk aversion in the fire service: report released today
Published: 29 March, 2012
The 2008 Galston Mine Incident report provides an independent assessment of the circumstances surrounding the death of Alison Hume who fell down a disused mine shaft in Galston on 26 July 2008.
The Galston mine incident inquiry report has been submitted to Scottish Fire Ministers, setting out to review the manner in which Strathclyde Fire and Rescue is now carrying out its functions in relation to the issues raised in Sheriff Leslie's report; to review whether appropriate steps have been taken, or require to be taken, by Strathclyde Fire and Rescue and across the Scottish fire and rescue services to address the findings of the report, thereby minimising the likelihood of this kind of tragedy happening again.
Fatal accident inquiry
The starting point of this latest report was the Determination made by Sheriff Leslie at the conclusion of the Fatal Accident Inquiry in November 2011.
Sheriff Leslie wrote, “…I was not directed to any legislation, or protocol, which allows me to accept the views expressed by Group Commander X, or Assistant Chief Fire Officer Y, that the type of rescue they would have required to undertake with Mrs Hume, was not within the parameters of their engagement… I found the evidence of Group Commander X, and Group Commander Z, to be focussed on self-justification for the action or non-action taken… I found their evidence to be bullish, if not arrogant, in their determination to justify the subservience of the need to carry out a rescue to the need to fulfil to the letter [their] Fire and Rescue Service ‘Brigade’ policy… Mr X, in particular, considered that the rescue operation was ‘a success’. In his view he had adhered to the policies and procedures set out by [their] Fire and Rescue Service… There had been no casualties other than the one to whom the Service was called upon to rescue...”
“Unfortunately this was not a successful operation: a woman died who had not only sustained survivable though life threatening injuries… I consider that the views expressed by Mr X and Mr Z were of a fundamentalist adherence to [their] Fire and Rescue Service policy. They rigidly stood by their operational guidelines… Assistant Chief Fire Officer Y conceded that the powers given to [their] Fire and Rescue Service under s13 and s14 of The Fire (Scotland) Act 2005 allowed a measure of flexibility to perform a rescue but only in suitable and reasonable circumstances… That statutory licence would have provided the mandate to the fire fighters who were anxious to deploy and adapt the equipment available to them to attempt a rescue…”
In the Galston Mine Incident Inquiry Report author Steven Torrie, QFSM HM Chief Inspector of Fire and Rescue Authorities, writes: “Out of this tragedy, there is an opportunity to address the growing risk aversion across the fire and rescue service, to properly support emergency responders who are faced with difficult challenges and to build a first class planning and response to specialist rescue incidents across the country.”
Mr Torrie says: “Alison Hume’s successful rescue was never guaranteed. However, the very long time she spent before being removed from the shaft greatly decreased her chances of survival. There was an inexplicable lack of focus on Alison’s medical condition, the risk she faced of hypothermia and the consequent time pressure for a rescue. The Inquiry was structured to consider the factors which influenced that timescale.”
Mr Torrie then said: “From my discussions with Alison’s family they feel a strong sense of grievance over the explanation of events they were given shortly after the incident. They believe that they only achieved a proper understanding through evidence which came out during the Fatal Accident Inquiry process. They are equally critical of the quality of operational command decisions taken by fire and rescue commanders.”
Growing cautiousness in the fire service
Mr Torrie remarked that fire and rescue services were increasingly being challenged and charged with failures and offences. “This is influencing the way in which the Services are operating.
“Amongst other things, this influence is creating a growing cautiousness within the Service. It is causing the Service to question whether it should be responding to unusual and hard to define incidents and whether it is appropriate to adapt and improvise in such circumstances. It is placing a growing pressure on individual officers who know that they may be held to account for often difficult command decisions. The scrutiny of operational incidents and command decisions which are made by managers, prosecuting authorities, Fatal Accident Inquiries and Inquiries such as this are of course intended, amongst other things, to act as an opportunity to reflect and learn. It is also the case that the outcomes of this scrutiny are causing a growing cautiousness in decisions made by fire and rescue services and operational commanders.”
The legal basis for Strathclyde Fire and Rescue responding to an incident of this type is unclear, said Mr Torrie: “Neither Strathclyde Fire and Rescue nor, to the best of my knowledge, any other fire and rescue service has made provision to deal with a Mines rescue. Setting aside absolute definitions of incident types – which might actually be contributing to the complexity in operational decision making for fire and rescue services – Strathclyde Fire and Rescue had specifically ruled out providing specialist line rescue and had chosen to defer to other organisations.”
Ongoing Development of Rescue Functions: The Fire and Rescue Framework published by Scottish Ministers should set out an expectation that the Scottish Fire and Rescue Service acts as a champion and coordinator of specialist rescue.
Learning Organisation: The Fire and Rescue Framework published by Scottish Ministers should set out an expectation that the Scottish Fire and Rescue Service behaves as a learning organisation.
Legal Definition of Duty: The Fire and Rescue Framework published by Scottish Ministers should direct the Scottish Fire and Rescue Service to define the parameters of its operational functions, and should explicitly recognise the need to adapt and improvise in unusual and difficult to define circumstances. All of this should fall within the scope of the community risk planning which fire and rescue services undertake.
Operational Command: The Scottish Fire and Rescue Service should carry out an audit of operational command training examining, in particular, risk critical decision making in unusual and hard to define circumstances. As part of the reform agenda, the Service should review operational command roles and implement the simplest possible structure for operational command.
You can download the full report below.