In July of 2009, a mid-afternoon fire in a residential high-rise in London killed six people, among them three children.
The fire occurred in Camberwell and the Guardian now reports that officials there are agreeing to plead guilty to breaking fire regulations.
Over the years since the tragic event there have been a number of reports and inquests, each one revealing relevant, if sometimes obvious, information on safety.
About the initial report, the Guardian stated that, “The FBU (Fire Brigade Union) said the inquiry was needed due to increasing public concern about the fire and because of “untrue” stories in the media about how they work.”
First, Lakanal House, a 14-story structure built in 1958, had neither sprinklers nor a central fire alarm system.
The fire apparently started in a faulty TV on the ninth floor and spread upwards and downwards through chases and voids, including on the exterior of the building.
It had but one stairwell and as a result, firefighters making their way upward were competing with residents trying to make their way down.
To add to the expected confusion, apartment numbers did not necessarily denote their actual floor. For example, apartment 81 was not on floor eight.
The London Fire Brigade commenced high-rise operations including establishing an upper floor operations center.
That center was forced to move to a lower floor when it was discovered that the fire had spread below them.
The move is described in a Coroner’s Report as “unprecedented”, placing demands on resources which in turn hampered rescues.
It appears that residents attempting to evacuate were told to go back to their apartment by firefighters and that call center operators were also telling residents to stay put in the firm belief they would be rescued.
One Coroner’s Inquest noted that there was no evidence that call center personnel had met minimum training requirements for a period of 15 years.
Call center personnel also failed to engage in “active listening.”
While there was confusion regarding apartment location and layout, one of those killed had given detailed information about her location and the conditions, yet the information was not properly shared or acted upon.
Many residents had balconies which could have been used for refuge or escape. They failed to utilize them because they were unaware of them or based on the advice they were given to remain in their unit.
There were six changes of incident commanders within a relatively short period of time. In a dynamic and rapidly changing situation it is hard to believe that some situational awareness, momentum and direction was not lost.
– “Two Ways Out” is still very good advice. I wouldn’t live in a multi-story building with one stairwell but if I did I would make provisions to escape from a window or balcony.
– If you are staying in an unfamiliar location, find the exits. If the window is one of them, make sure it opens.
– If there is evidence of a fire, make your exit instantaneously. In this and other incidents, safe exit was complicated once firefighters arrived and commenced operations. Be out before they get there.
– Be skeptical about what you are told by the experts and continuously evaluate your situation regarding staying or going.
– Know your first due buildings, especially the “quirky” ones.
– Recognize indicators of a degrading situation: confusion, unaddressed rescues, fire spread (including below you) or loss of effective communication.
– Create an on-site ready reserve of more than you think you need to rapidly address an unexpected development.
– Divide tasks to avoid being overwhelmed.
– Don’t dismiss the value of a keen observer/monitor solely tasked with assessment of environment, deployment and outcomes.