Fire commanders delayed the recovery of a woman lying at the bottom of a disused mine shaft, with fatal consequences, because they were overly preoccupied with adhering to management’s rescue policy, a fatal accident inquiry has found.
Alison Hume died after spending eight hours at the bottom of the mine shaft, into which she fell around midnight on 25 July 2008. By the time she was brought to the surface she was profoundly hypothermic and had suffered a pneumothorax, broken ribs and a broken sternum.
In his determination on the inquiry, published on 16 November, the Sheriff for North Strathclyde, Desmond Leslie, said Mrs Hume’s death could have been avoided if
Strathclyde Fire and Rescue Service had carried out a rigorous risk assessment of the situation and allowed it to prevail over its “restrictive” corporate policy.
The Sheriff also found that the 44-year-old’s death could have been prevented had the following reasonable precautions been taken:
- early identification by the Police and Strathclyde Fire and Rescue Services of the stability of the mine shaft and surrounding area;
- early assessment of Mrs Hume’s medical condition, and appraisal of the likely dangers of a prolonged stay in cold and wet conditions; and
- a thorough understanding of the capability and properties of line-rescue equipment (also known as safe working-at-height – SWAH – equipment), and the level of training of fire-fighters in the use of that equipment.
The inquiry heard that the Fire Service issued an internal memorandum on 14 March 2008, which stated: “[T]he SWAH equipment will not be used to effect rescues using work-positioning systems of work until further notice. In the event of circumstances arising which can only be resolved in this way, whether personnel are equipped with SWAH equipment, or not, incident commanders will request assistance with operations control from Strathclyde Police Mountain Rescue Team, Trossachs Search and Rescue Team, or, whether appropriate for coastal, cliff and shoreline mud rescues, HM Coastguard’s Rescue Teams.”
However, an amended memo on 27 March 2008 gave limited licence for the use of SWAH equipment by stating: “This guidance does not preclude the use of SWAH equipment to secure any casualty to prevent their further injury, or to prevent the deterioration of the existing circumstances”.
The Sheriff concluded: “An unwavering adherence to the memorandum of 14 March 2008, without greater appreciation of the limited licence provided in the later memorandum of 27 March 2008, was manifest in an inflexible and non-discerning approach to the rescue attempt.”
He added: “There is little doubt that the rank-and-file fire-fighters in attendance were anxious to conduct a rescue as quickly as possible, but were prevented from doing so by the superiors.”
The Sheriff also identified defects in the system of working as contributory factors to Mrs Hume’s accident, or her death. These included:
- Inadequate knowledge by Strathclyde Fire and Rescue Service and the Police of the range of potential rescue resources available to assist in a rescue operation, and consequent failure to communicate with these resources;
- Lack of multi-ability training for emergency services personnel; and
- Inadequate pre-planning for mine and mine-shaft rescue.
Following the publication of the inquiry’s findings, the Service’s director of operations, Assistant Chief Officer David Goodhew, said: “Despite the fact that mines rescue is a highly specialised skill, and fire crews are neither trained nor equipped to deal with this specific situation, the Sheriff himself acknowledged fire-fighting personnel risked their own lives to tend to Alison in the shaft and stabilise her condition.
“Our first instinct was to bring Alison to the surface as quickly as possible using a harness. However, medical advice is that using such equipment could have put her life at extreme risk due to the serious nature of her injuries. Specialist stretcher equipment to bring her up horizontally was seen as critical to any rescue attempt, and a decision was made to wait for police mountain-rescue services to bring their equipment to the scene.”
He confirmed that the Service will be studying the report, in conjunction with its counterparts in the Police, mines-rescue and ambulance services, to implement the lessons learned.
Since Mrs Hume’s death Strathclyde Fire and Rescue Service has established a rope-rescue unit in East Kilbride, where all fire-fighters from the Service will be trained specifically in rope-rescue techniques.
Earlier this year, the Service’s chief officer Brian Sweeney said fire-fighters are more fearful of health and safety legislation and the prospect of being prosecuted than of the dangers they face when saving lives.
Also, in April, the HSE issued new guidance aimed at helping the Fire and Rescue Service balance their operational and health and safety duties.
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The Strathclyde fire department should be ashamed of themselves, having worked in the fire dept at Jaguars, I have had first hand experiance of the ongoing training that is given on a regular basis. These firefighters who are valient at all times due to unforseen accidents by employees would not have hesitated to erect a tripod apparatus having had the training and gone down and carried out the rescue as neccessary. what is the Strathclyde fire dept coming to.( SHAME ON YOU)
I have posted thoughts on tis before when the Chief Fire Officer was blaming H&S for the tragedy stating it was him who no doubt possibly allowed for t training budget sto be cut.etc I wonder whether Ms Hume’s family will be taking legal action against the fire service. As an ex mines rescue man my training never went as far as far as rope access, it was all on the level. The specialists are cave rescue (nearest base in Yorkshire) so the post tragedy action is appropriate. still v tragic
Imagine the scenario if the senior officers had decided to effect a rescue immediately and one of the fire-fighters had been killed. The senior officer would have been slated for going against the fire service policy and may have subsequently faced a manslaughter charge as happened to 3 senior fire officers of Warwickshire Fire and Rescue Service. The HSE also prosecuted the Met Police over the Jean Charles De Menezes case. What message does the HSE wish to convey exactly ?????????
Damned if you do and damned if you don’t! The report says they attended her but risk of injury by moving was considered greater than stabilising where she was. No doubt if they had rescued in a harness but crippled her then voices would now be shouting she should have been left where she was! Isn’t hindsignt wonderful!!
In the event of a death, what is the law’s view regarding an attempt to save a life despite the risks. In the cited case of the woman in the mine shaft, would the Fire personnel have been judged appropriately within the law of trying to save her life sooner by removing her from the life threatening situation? My forces training of “Keep them breathing – Stop them bleeding” has always provided any act done in good faith. Your views???
All comments including my own talk about what happened. We all know what happened!
If you were faced with a similar incident and you were the officer in charge – what would you have done?
This is simply disgraceful and the outrageous “spin” from the services Director of Operations does him no credit at all. He needs to start from what was established by the Sheriff which was that a lady lost her life unnecessarily and a crew who had the equipment and capability to rescue her were prevented from doing so by an executive who lacked the knowlege to direct the rescue and the courage to allow others to proceed. I have the experience and qualification to know this and so does he.
This is not the first time that fatilities have occurred because of bureacratic systems employed by emergency services.
Why is it that, only now, are fire-fighters in Strathclyde being trained in line and rope rescue?
This used to be a part of the recruit course and regularly practiced on fire stations.
It’s both a ‘criminal’ failure and a severe lack of care and professionalism, at the very least.
Well said Ray – every fire officer in the land should “tak[e] responsibility for [their] actions” and “get[..] on with it”..!!
Damned if you do, damned if you don’t I do agree with. However, isn’t a major point being missed? How was the poor lady able to fall down a mine? Where were the barriers? I don’t see any comments from the Sherriff on that. If she hadn’t been able to fall, there would have been no need to rescue her.
Unfortunatly it is no longer just health and safety. Have you had an accident reciently? do you want shed loads of money for a hurried rescue attempt? Are you paralised from the waist down? No win no fee. Roll up Roll up. Sue Strathclyde fire service for thier entire annual budget. The world has gone mad. We need to rethink out priorities.
For the life of me I cannot see any relevance of the Asst Chief Officer’s comments in respect to the Sheriff’s criticisms. It sound like the ACO is putting a spin on what is very sad and tragic case. Sometimes saying ‘no’ and not taking responsibility for one’s actions is easier than getting on with it.
James, no one is obliged to put their own life at risk by saving another. However, if you join the fire and rescure service it follows there will be occasions where you will put yourself in danger – to save others.
I don’t think it is the fault of the fire officers, but their commanding officers who would not sanction the rescue without all the boxes being ticked. I agree to a point that it is a case of damned if you do…but surely, the commanding officers got it wrong on this occasion?
There was a one page article in the DM devoted to this incident today – sad reading. Moreover, in the Comments section on p18 – ‘Truly, the tick box mentality displayed by this tragedy is one of the most depressing aspects of modern life. It saps initiative. responsibility and most of all common sense.’
Regrettably, I cannot disagree with one word from the above statement.
She fell down a disused mine shaft dating from the 1920’s, probably out in the country somewhere which had been forgotten with time. In the context of the incident and lack of rescue it is not really relevant anyway – she fell and was not suitably rescued.
Eric, I agree that there have ben some mixed messages from both the HSE and CPS regarding recent h&s prosecutions. That said, I am always wary of using the worse case scenario as an example. It seems there will always be extreme ends of the norm and this in itself should not be used as an excuse for not doing something.
Lest we forget, good health and safety management is about ensuring things get done as safely as possible, not preventing them from getting done.
Good question James. I would like to think that I would do the right thing in a given situation. When I was asked many years ago about a particular h&s duty regarding a young lady I responded – imagine she was your daughter or niece, what would you do in the circumstances. I cannot believe if the person had been the daughter or niece of those in attendance they would not have done more.
‘She was not rescued, period !’
Stating the bleeding ovbious…what was your point?
The balance between safety and the duty of care has been distorted. Firemen have a moral and legal obligation to save lives and property. The notion that, in doing so, may place their lives in danger, and would therefore be ‘unsafe’, is plainly rediculous.
The OIC should have the training and experience adequate enough to make a split decision in favour of the person (s) to be rescued. It is embarassing to read such stories. Rob Bidgood. MIFireE; NDipSAM; CMIOSH.
She was not rescued, period !
What a disgrace, those responsible should lose there jobs. My thoughts are with Alison’s family.