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HEREFORD AND WORCESTER FIRE BRIGADE ,

Interim Report No. ·1

The Fire Service ! Colle /

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00157424 : .1

FIRE

SUN VALLEY POULTRY LTD. Widemarsh Common

Hereford 11 :44 Hrs. 6th September 1993

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•• • • SECTION 1

• I SECTION 2

- SECTION 3

I - SECTION 4

I SECTION 5

-I SECTION 6

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SECTION 7

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J APPENDICES

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CONTENTS

THE PREMISES:

(1) Occupancy (2) Description of Main Structure (3) Recent Building Works

SUPPOSED CAUSE OF FIRE: (1) Supposed Cause (2) Historical Perspective (3) Other Causes Considered

DISCOVERY OF THE FIRE:

(1) Discovery (2) Subsequent Actions by Sun Valley Staff (3) First Call to the Brigade (4) Initial Mobilisation by Brigade Control

ACTIONS ON ARRIVAL OF TIlE BRIGADE:

(1) First Officer in Attendance (2) First Appliance in Attendance (3) Arrival of Remainder of the Initial Attendance (4) Fireground Messages

ACTIONS FOLLOWING THE FIRST ASSISTANCE MESSAGE: (1) First Officer of Supervisory Rank (2) Arrival of Subsequent Appliances (Make Pumps 4) (3) Strategy for Attacking the Fire (4) Fireground Messages (5) Arrival of Subsequent Appliances (Make Pumps 6)

ACTIONS FOLLOWING ARRIVAL AT THE WIDEMARSH COMMON END OF BUILDING

(1) Actions on Arrival (2) Events Following Receipt of the BA Wearer

Distress Message (3) Evacuation of the Building

SUBSEQUENT OPERATIONS

FATALITIES

Corbett Block - General Layout Plan Corbett Block - Plan Detailing Location of Insulation Materials Corbett Block - Plan showing Location of Fatalities and Process Plant Corbett Block - Aerial Photographs Before and After the Fire

... SECTION 1

• THE PREMISES:

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(1) Occupancy

(i) The premises are occupied by Sun Valley Poultry Ud., who process chicken and other poultry products. Corbett Block was one of several self contained units within the factory complex. Approximately 500 people were employed within the building, where meat products were prepared and cooked.

(ii) The premises were originally certificated under the Fire Precautions Act on 30th May, 1984. Following major refurbishment and alterations, the certificate was re-issued on 30th July, 1993.

(2) Description of Main Structure (i) The building is a composite of earlier structures which have been modified and extended to form the current arrangement known as Corbett Block. (ii) The building is predominantly steel framed with brick or block outer walls surmounted by a steel roof. Certain external walls had steel profiled sheet sections.

(3) Recent Building Works (i) The premises have been the subject of a programme of continuous development and extension during recent years.

(ii) A new steel roof has been provided for the main compartment of the building, this work being completed within the last six months. The roof was installed without any form of ventilation. The ouly penetrations of the roof structure were vents and ducts from processes within. Due to the necessity for a temperature-controlled environment within the building, each of the process areas had been provided with plastics-based insulation during the last 2 years. (iii) The horizontal insulation took the form of a newly - installed suspended ce.iling with panels constructed mainly of 65mm rigid polyurethane foam slab sandwiched between two layers of steel. Each panel measured approximately 6m x ·1.3m. A large tract of the suspended ceiling was recently replaced by 150mm polystyrene foam panels of similar construction.

(iv) The large void created above the suspended ceiling was undivided throughout its entire area and was not provided with fire resistant cavity barriers. (v) The vertical insulation comprised panels of similar construction to the suspended ceiling. Panels were fixed to most of the partition walls and to the internal faces of the external walls. The core of these panels was 65mm polyurethane and lOOnun polystyrene rigid foam. The wall panels which divided the Frying Area from tbe remainder of the main process area was faced witb Supalux fire resistant boarding.

(vi) Calculations have been carried out to ascertain the quantities of foam plastic insulation material present within the building. The calculations are based on an average suspended ceiling height of 4 metres.

(i) POLYSTYRENE: 100mm Wall Panels 305m3 150mm Ceiling Panels 624m3 TOTAL 929m~

(ii) P0ls YURETHANE: 5mm Wall Panels 70m3 65mm Ceiling Panels 408m5

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SECTION 2 SUPPOSED CAUSE OF FIRE: (1) Supposed Cause

(i) The circumstances surrounding the fire, including the cause, remain subject to investigations currently being carried out by the Health and Safety Executive. (ii) The cause attributed by the Brigade Fire Investigation Team will be, unless subsequent technical investigations by the HSE prove to the contrary, a malfunction in the item of plant known as the Radio Frequency Defroster.

(2) Historical Perspective (i) The Radio Frequency (RF) Defroster consisted of four electrically operated units designed to defrost frozen portions of meat which were laid on plastic trays. The unit was similar in operation to a large microwave cooker although it operated on radiowave frequencies.

(ii) The unit was provided with stainless steel inlet and exhaust flues. The inlet flue drew air into the defroster, from the roof void area. The exhaust flue was assisted by an electric fan ona 1'3~sed tirrough the ceiling and the roof to open air. Neither of the flues was prvvided with insulation where they passed through the suspended ceiling.

(iii) The unit, a prototype design, was manufactured by Petrie McNaught Limited of Macclesfield, Cheshire. It was installed approximately two and a half years ago. (iv) There had been a number of problems with the unit, some of which had resulted in fires. The brigade had attended a previous fire involving the unit on the 4th May 1993, and a fire had also occurred within the unit at approximately 0800 hrs on the same day as the subject of this report. The fire which occurred at 0800 hrs was dealt with by Sun Valley staff and the brigade was not called. Maintenance personnel carried out work intended to rectify the fault and the line was put back into operation. (v) The unit had undergone a mechanical modification to the transport belt during the previous weekend (4th/5th September).

(3) Other Causes Considered (i)

Cii)

A number of potential causes of fire in the roof void above the RF Defrost area were considered. These include electrical and mechanical causes, contractors and maintenance workers, malicious ignition, smoking materials, spillage and leaks of flammable liquids and gases.

Investigations failed to reveal any significant probability of cause other than the malfunction in the RF Defroster plant.

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SECTION 3 DISCOVERY OF TIffi FIRE (1) Discovery

Following the fire at 0800 hours on the same day, the same operator of the RF Defrost plant visited the toilet and canteen and, on return to the Defrost area realised that there was a further fire in the plant (indicated (4) on the plan attached as Appendix 'N).

(2) Subsequent Actions by Sun Valley Staff

(3)

(4)

(i) The operator informed a maintenance fitter of the fire at some time between 1125 and 1142 hours. The fitter reported the matter to a second fitter, who went to the plant and saw that the side of the unit was glowing red hot and that there were flames issuing from the canopy, accompanied by thick black acrid smoke. (ii) The second fitter actuated the fire alarm then attempted to extinguish the fire with 3 x 5kg carbon dioxide extinguishers which were discharged into the canopy of the machine. Realising that he could not control the fire, he evacuated the area together with the other workers.

(iii) The premises were evacuated within 2 minutes, and a roll call of the 300 workers was completed within 5 minutes of the alarm being sounded.

First Call to the Brigade (i) The established procedure within the factory places the responsibility for calling the fire brigade with the security staff, who telephone the brigade immediately on hearing the fire alarm sound.

(ii) Following discovery of the fire between 1125 and 1142 hrs, the security log states that the call to the brigades mobilising control was made following an alarm which was actuated at 1142 hrs from Corbett Block.

Initial Mobilisation by Brigade Control (i)

(ii)

On receipt . of a call from Sun Valley staff at 1144 hrs stating that there was a fire in the roof space within Corbett Block, Brigade Control ordered the following mobilisation:

Officer:

Appliances:

Station Officer

461 (Wholetirne Water Ladder based at Stn. 46 Hereford) 462 (Retained Water Ladder' based at Stn, 46 Hereford)

At the time of mobilisation, the wholetirne personnel from Station 46 Hereford were engaged in off-station training at a scrap yard at Holme Lacey, Rotherwas, some four miles distant.

(iii) The number of personnel on duty at Sin , 46 on the 6th September had been reduced to 7 due to sickness. The watch had with them appliance 461, together with the Emergency Tender from Stn, 46. On receipt of the mobilising message 461, with Sub Officer in charge, proceeded to the fire with a total of 5 riders, Leading Firefighter remained at the scrap yard with Ft Morris to make up the gear which had been used before proceeding to Stn, 46 to n;;ni the Water Tender 463,

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SECTION 4 ACTIONS ON ARRIVAL OF THE BRIGADE (1) First Officer in Attendance

(i)

(ii)

Station Officer booked in attendance at 1155 hrs. and was met by a company engineer near to location (1) on the plan. The engineer informed him that there was a fire above a fridge which had set fire to the roof within the RF Defrost area.

Sin. 0 could see black smoke permeating from the roof and blistering of paintwork of the eaves fascia at high level. Black smoke was beginning to appear from the building near the rarnpway area.

(2) First Appliance in Attendance (i) The first appliance in attendance was 461, which booked in attendance at 1156 hrs. (ii) Sin. O. committed 2 BA wearers from 461 with one hose reel jet into the building toward the RF Defrost area via the open roller shutter door (2) which served the loading dock. With the aid of the plan which had been provided hy the engineer, Stn. 0 briefed the men that they should advance to" urJ the fire and report the situation to him.

(iii) The tearn withdrew after a short time and requested a main jet. They then re-entered and were later joined by Sub 0 in BA. While making a concerted effort to fight the fire they were ordered to withdraw by the Entry Control Officer who thought that he had noticed a possibility of collapse of the structure around their entry point. Satisfying himself that there was no danger, Sub 0 re-entered tbe building with the BA team and resumed operations in the RF Defrost area. (iv) Sin. O. had, in the meantime sent a 'make pumps 4' message. (v) The tearn was again withdrawn, due to the possibility of a flashover. After a brief discussion between Stn 0 and Sub 0 it was agreed that there was sufficient ventilation of the fire in this area to make the likelihood of a flashover minimal and the BA tearn again re-entered the building, this time finding that the doorway from the loading dock into the RF Defrost (3) had become blocked by fallen debris. The tearn was forced to alter their objective, and began to direct their jet into the b1!ilding from doorways. The crew remained in this location until they were withdrawn by Stn Officer who had received a radio message from ADO informing him that ACO bad ordered an evacuation of the building. The team were stood down from BA operations, having earned out three consecutive wearings. They were subsequently ordered not to re-enter the building.

(3) Arrival of Remainder of the Initial Attendance 462 (Retained Water Ladder Srn. 46) in attendance 1200 hrs.

(4) Fireground Messages 1200 hrs. Stn. O. : 'Make Pumps 4.

Building Heavily Smokelogged. 2 BA, 1 Hose Reel'

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SECTION 5

ACTIONS FOLLOWING THE FIRST ASSISTANCE MESSAGE (1)

(2)

(3)

(4)

(5)

First Officer of Supervisory Rank Brigade Control infonned Assistant Divisional Officer the nearest supervisory officer, of Stn. O. fireground messages. He proceeded to the incident, booking in attendance at 1207 hrs.

Arrival of Subsequent Appliances (Make Pumps 4) 431 (Retained) Stn. 43 Fownhope in attendance 1215 hrs 463 (Mixed) Sin. 46 in attendance 1216 hrs.

Strategy for Attacking the Fire (i) The engineer infonned Stn. O. that the only other access to the area

(ii)

involved in fire was an entrance at the Widemarsh Common end of the building. Following a brief discussion of the situation with Sin. O. and the engineer, ADO made the decision ta attack the fire from two sides and that he would take charge of operations at the Widemarsh Common end of the building whilst Sin. O. would remain at his current location. ADO then proceeded toward the opposite end of the building with the company engineer.

Fireground Messages 1211 hrs ADO 'Make Pumps 6' Arrival of Subsequent Appliances (Make Pumps 6) 523 (Retained) Stn. 52 Leominster in attendance 1223 hrs 521 (Retained) Stn. 52 Leominster in attendance 1233 hrs

SECTION 6 ACTIONS FOLLOWING ARRIVAL AT THE WIDEMARSH COMMON END OF BUILDING

(1) Actions on Arrival (i) On arrival, ADO held further consultations with the engineer. It was decided that access should be gained to the main compartment via doorway (7). (ii) ADO committed 2 BA wearers, LFf Davies and Ff Morris, at 1225 hours into the building via doorways 7, 10 and 11. Their instructions were to carry out a reconnaisance of the main compartment and, if possible, to check the roof space. Ff Morris led the team into the building, taking a portable radio set with him. . .

(iii) ADO then left the entry control point together with the engineer to investigate the possibility of using external staircases and ladders to gain entry into the roof void .

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(2) Events

(i)

(ii)

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Following Receipt of the BA Wearer Distress Message The BA entry control officer, FF maintained radio communications with the the BA team.

At approximately 1235 brs a message was received from tbe BA team to tbe effect that they required assistance. LFf reported tbis to ADO who then ordered that a 'BA Emergency' message be sent to Control. The two Emergency BA Wearers were committed into the building at 1237 hrs. via the same entry point together with a hosereel jet. At 1240 hrs. a further team of two BA wearers were ordered to enter and lay a guideline. On finding that tbe compartment was extremely hot, this team withdrew and re-entered with a main jet. A succession of further messages were received from FF Morris, of an enquiring natur~ . These teams found that the fire was well developed within the main compartment. The latter team opened door (11) into the main compartment and were met with a blast of heat. They found that the doorway was blocked by fallen debris, and were forced to play their jet on the immediate area. They heard explosions and loud noises while they attempted to fight the fire .

(iv) Three further teams of two BA wearers were committed into the same entry point at 1247, 1250 and 1258 hrs.

(y) St:. O. arrived at the incident and was ordered by ADO tn takc control of the SCer.e around the 3A Entry Point !!lro\.!gh which LFf Davies and Ff Morris had been committed. He looked at the BA Board and saw the inscription 'BA Emergency'. Station Officer was asked by Station Officer to ensure that a 'BA Emergency' message had been sent. (vi) SIn.O. attempted to find other points of entry into the main factory enclosure from outside the building. Using a large axe he gained entry into three adjacent doors, two of which lead into small enclosures, the third (12) leading into a quality control kitchen area which in turn led into the main enclosure. (vii) Three 2-man BA teams were committed into the building by means of this doorway. (viii) LFf continued to make repeated attempts to communicate with Ff Morris by means of the personal radio, without success.

(ix) One of the BA teams managed to locate LFf Davies, at location (14) who was trapped by his legs under pipework and other items which had fallen on him. They made a request for an EPCO jack and attempted, unsuccessfully, to release LFf Davics who had been subjected to severe burning and was believed to be dead by this time. BA teams made a concentrated effort to release Lff Davies under extremely hot conditions. It was necessary to spray those working inside the compartment with jets to enable them to work. Determined efforts continued in extremely arduous conditions to release LFf Davies until firefighters were evacuated from the whole of the building. (3) Evacuation of the Building 11 (i) ACO was informed that there was a danger of two large liquid oxygen tanks exploding, and that this would create a major hazard to all firefighters working in the area.

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(iii)

SECTION 7

The turntable ladder which was working in the area of the rescue operations (12) was moved back to the perimeter of the factory and all firefighters were withdrawn. Within one or two minutes of this evacuation there was a major eruption from the south east corner, followed two or three minutes later by a further eruption. The nature <>f these eruptions remains the subject of further investigation.

SUBSEQUENT OPERATIONS (i) Following the evacuation of firefighters from the premises measures were taken to increase the water supplies to fireground pumps in order to mount a consolidated attack on the fire. Curtain sprays were organised to protect unaffected buildings and aerial appliances were brought into use as water towers. Ground monitors were also got to work.

(ii) Due to the severity of the fire it was some time before the area in which it was believed that the casualties were located could be brought under control to the extent where it was possible to commit firefighters. (iii) A senior officer took charge of the reCOVeiy apclaiion, and directed crews to cool the area inside the building by the use of jets. The officer entered the main compartment together with other officers to make an appraisal of the situation. He found Leading Firefighter Davies and ascertained that he was trapped beneath sheets of steel and pipework which were being pressed down by steel roof members. The debris was still very hot and the temperature within the compartment was still too high for personnel to work within it. Steel panels were removed from the building at high level in order to ventilate the compartment and jets were employed until working conditions improved.

(iv) The officer realised that Leading Firefighter Davies was clearly dead. A variety of RTA rescue equipment was used to free the body from the steelwork and Leading Firefighter Davies was removed from the building. (v) A systematic search for Firefighter Morris was then organised. It was necessary to remove quantities of steel panelling which had formed the suspended ceiling and other debris before the search could be continued effectively. The body of Firefighter Morris was eventually found in location (15) adjacent to the spiral chill plant, some 13.5 metres away from the body of Leading Firefighter Davies. (See also Appendix 'C').

(vi) The bodies of LFf Davies and Ff Morris were recovered and conveyed to the mortuary at Hereford County Hospital.

(vii) Station Officer visited the mortuary at 1730 hours and identified the bodies of both men.

(viii)

(ix)

(x)

(xi)

The officers who comprised the Fire Investigation Team visited the 1ll0rtuary at approximately 2200 hours that evening, and inspected the bodies in order to add perspective to the circumstances in which the firefighters had died. The breathing apparatus board which held the tallies of the deceased firefighters was impounded by an investigating officer on his arrival at the fireground at 1437 hours, and the details recorded upon it were preserved. The BA sets which had been used by the deceased were impounded after removal from the bodies. The sets were then placed into plastic bags which were secured.

The BA sets were subsequently examined by a breathing apparatus specialist employed by the Health and Safety Executive in the presence of brigade investigating officers. The BA set No. 142 worn by FF Morris was found to be working with the exception of the exhalation valve, which was sticking slightly.

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PLAN DETAILING LOCATION I

OF I FOAM PLASTIC IN SU LA T I O~I I1 MATERIALS

>< 15Cmm f'ce..YS1\'1i!)1t: CM[ CIl!JNG PIJIELS

>< 6SR>rn !'Cl 'IlIIit.1NAN£ CORE CDIJIIB PA.I!D.S

6511!m ptl,'l\Jik-rHAl1! COfI£ I':'AIJ. P.&.I:rl.S

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-HEREFORD AND

WORCESTER FIRE BRIGADE I

I SUN VALLEY POULTRY Ltd

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CORBETT BLOCK 1

WIDEMARSH COMMON SITE I GRANDSTAND ROAD i HEREFORD ,

I;;;te : APRIL 1993 Ref No : 46-53882 i

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APPENDIX C

LOCATION OF FATALITIES

AND

PROCESS PLANT

. HEREFO RD AlID WORCESTER

FIRE BRIG}J)E· SUN VALLEY POULTRY Ltd CORBETT BLOCK WlDEMARSH COMMON SITE GRANDSTA.ND ROAD HEREFORD