Hampshire Fire & Rescue Service releases full report into deaths of Alan Bannon and Jim Shears at Shirley Towers

James Shears and Alan Bannon, who served at St Mary's fire station, lost their lives while tackling the blaze at the high rise block of flats.

The inquest into their deaths returned a verdict of death by misadventure.

The publication of the final 179-page report, which details the events of the incident and shares the service's recommendations and findings, marks the end of Hampshire's official investigation process.

Among the findings were:

- Firefighters' gloves had shrunk in size, in some cases by as much as a third.

 “Considerable difficulty” was encountered when identifying some personnel when viewing CCTV images.

- Temperatures rose rapidly to the point that the safety of firefighters was endangered.

- CCTV footage showed there was some misunderstanding about which of the two lifts had been designated as the fire lift.

- The first crew committed to the incident did carry at Thermal Imaging Camera (TIC) but did not use it to locate the fire. Post incident trials revealed that TICs can be used to locate fallen cables.

- Initial crews entering flat 72 did not locate of extinguish the fire in the lounge before turning right and ascending the stairs to the bathroom and bedrooms beyond. The fire developed in the lounge behind them and spread to the adjacent kitchen.

- The first breathing apparatus emergency team tasked with rescuing Red Team 2 “did not take with them any means of providing an air supply to the missing firefighters despite their entry to the flat being several minutes after Red Team 2's projected time of whistle.”

- No specific rescue plan was undertaken for residents until sometime into the incident. Shirley Towers has a “stay put policy” for residents in the event of a fire. The occupants of five flats received fire survival advice and throughout the period in which advice was being given the residents were repeatedly told that the fire and rescue service was on its way. Several residents sounded very distressed and in need of urgent assistance.

- Video shows a number of breathing apparatus board entries marked on the wall of the seventh floor. These entries were made as a result of insufficient breathing apparatus control boards being available at the point of entry and the need to commit additional breathing apparatus crews.

- The fire alarm at flat 72 was not silenced for several hours. The alarms emit a very loud audible alarm that can mask the operation of ADSUs, disrupt conversations and interfere with radio messages.

- Incorrect intelligence led fire crews to force open several front doors in their attempts to locate the correct fire escape door to flat 72.

- Several large pieces of the reinforced concrete roof structure in the kitchen were noted to have broken loose and fallen to the floor during the course of the fire. It is known as “spalling” and is a well-known feature of reinforced concrete in fire situations.

- Mounted plastic cable trunking had softened or melted as a result of the fire in flat 72. The trunking carried a variety of cables and was present in every room of the flat. It allowed the cables laid within it to fall free. The cables are unlikely to have been very visible in smoky conditions prevailing during fire fighting operations.

- Control tapes revealed that fire control was aware, from conversations with residents via telephone, that fire crews were breaking into flats by forcing entry.

- Initial deployment of crews to Shirley Towers was made without precise knowledge of which floor the fire was on and the correct floor on which to establish the Bridgehead.

- CCTV images showed a number of fire service personnel not wearing full personal protective clothing during the incident, notably helmets and in some cases fire tunics.

- A bodyguard device fitted to breathing apparatus sets, which is commonly understood to measure temperature, air consumption, cylinder contents and operation of the ADSU, showed data downloaded from the device was often prevented because of an inherent software failure that provided corrupted data.

- Control tapes indicate that some communications with fire control were inappropriate. For example, officers not yet mobilised to the incident contacting control for details. The form of address between callers and control was less than formal with the standard greeting generally “hello mate”. This familiarity was evident in personal radio communications. The use of first names was widespread which can lead to some confusion.

Among the recommendations from Southampton coroner Keith Wiseman, through rule 43: recommendations for consideration in relation to the risk of fire in high-rise buildings, included calls for social housing providers to consider the retro-fitting of sprinkers in all existing high rise buildings in excess of 30 metres in height, particularly those highlighted by fire services has having complex designs.

Chief officer John Bonney said: “The release of our final investigation report into Shirley Towers represents a significant landmark for us.

“The investigation work that has taken place in the last three years since the incident has required us to be open and honest with ourselves and this has at times been painful and challenging.

“But it was vital to ensure that we were able to learn from the event so that the safety of the public, as well as firefighters, could be improved.

“We continue to support families of Jim and Alan and this report and DVD follows our commitment to them to reduce the chances of a similar tragedy in the future.

“The Coroner made a number of recommendations following the inquest calling for action from Government. Our report echoes many of these findings and we will do everything in our power to ensure they are acted upon.

“We have made many improvements to our Service since Shirley Towers and an overarching programme is in place. This will continue into the years that come as we provide the best service we can to the communities of Hampshire.”

Alan Bannon's sister, Lin Trott, said: “Alan's family are aware that Hampshire Fire and Rescue are working closely with Southampton City Council, but in our opinion the vast majority of local authorities do not appear to be as active, or as aware of the Rule 43 recommendations as Southampton are. We feel that this needs to be more actively communicated and given support by the Government.”

Read the full report: