Fire chiefs delayed mine-shaft rescue

Fire commanders delayed the recovery of a woman lying at the bottom of a disused mine shaft with fatal consequences.

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.