September 23, 2008
The New Zealand Fire Service Commission’s report into the explosion and fire at the Icepak Coolstore in Tamahere, Hamilton, resulting in the death of Senior Station Officer, Derek Lovell, and seriously injuring seven other firefighters, was released today.
The report found that the explosion and fire was almost certainly caused by a leak of flammable refrigerant ignited by an electrical event, when the firefighters were in the plant room.
The New Zealand Fire Service Commission appointed an inquiry team into circumstances surrounding the incident and the NZ Fire Service’s preparedness.
The report also found that:
- Based on the information available at the time, the NZ Fire Service was adequately prepared for this incident. Operational instructions were in place and were followed. The only possible exception was that firefighters who enter a building where the atmosphere is potentially irrespirable should wear and use breathing apparatus; in this instance, it is not certain whether the firefighters had turned on their breathing apparatus. However, whether or not they had done so did not affect the outcome of the incident in this case. Had the firefighters suspected a flammable atmosphere to be present, their training would have required them to withdraw at once.
- Personal protective equipment performed according to expectation. Full structural firefighting clothing, where it was worn, provided protection against burns but is not designed to protect against blast injury. The appliances and other equipment at the scene also performed as expected, with the exception of the prototype hazmat-command unit where some aspects of its pilot communication and information technology systems need to be re-examined.
Specific matters in the inquiry team’s recommendations include the following:
- The Hazardous Substances and New Organisms (“HSNO”) regulations and standards should be amended so that stationary refrigeration systems, and the refrigerant they contain, are subject to appropriate controls.
- All large-scale flammable gas installations should by law require inclusion of stenching agents in the gas.
- The regulatory regime as a whole should be reviewed to promote the sharing of information about hazardous substances between regulatory and other interested agencies.
- The current rural/urban fire legislation should be analysed in relation to risk planning and control of fires in buildings throughout New Zealand.
- Agencies need to share information about buildings using nationally consistent formats.
- Fire Service pre-incident planning processes need to identify high-risk buildings, including those that are outside the urban fire district.
- The current Fire Service instruction on significant incident and post-incident support should be reviewed to capture lessons learnt in this event.
- Fire Service operational instructions on the use of gas detectors should be reviewed to provide more detailed information.
- Formal security and scene handover procedures for major fires should be improved.
The inquiry identified nine different factors, any one of which could have avoided the risks and injuries to the responding firefighters:
- HSNO regulations applied fully to this installation
- prior notification to the Fire Service of hazardous substances at the premises
- receipt of an application for approval of an evacuation scheme
- pre-incident planning and familiarisation visit by local Fire Service staff
- Fire Service awareness of the large-scale use of flammable refrigerants in New Zealand
- warning signage at the premises
- stenching agent present in refrigerant gas
- flammable gas detection on the premises alerting crews
- crews using a portable gas detector.
This indicates that the fundamental cause of the incident may lie in part in systemic defects in the regulatory environment and the communication between the various regulatory agencies. This is an issue that may deserve wider investigation by the Government.
