Learning from fires
Much knowledge can be obtained through investigation of fires. Fire investigations give increased knowledge about how and why fires start, why fires developed as they did and how to prevent it happening again. SP Fire Research assists with independent investigations of fires on request from the police, insurance companies, the justice administration, other authorities, lawyers and private companies.
The Norwegian police must, by law, investigate all fire incidents to determine if the fire was an act of arson. It is, however, a fact that the police do not investigate all fires. In the busy daily routine with scarce resources some fires are unfortunately not investigated as thoroughly as they ought to be. This may especially be the case for incidents where the fire cause seems to be obvious.
From the police’s point of view this may seem as a reasonable use of resources, but the field of fire safety – and the society – will fail to obtain valuable knowledge. In our opinion there has been too little focus on fire investigation to reveal why fires started, how and why they spread, and which safety barriers worked and which did not. We see a need for a systematic approach to fire investigation to be able to answer these questions.
New Norwegian regulations require that fires are investigated
The Norwegian Fire Prevention Act requires that the municipalities shall investigate incidents to achieve continuous learning and improvement of the work related to accident prevention and preparedness. In the new regulations that came into force 1st of January 2016 this is explicitly stated as follows (our translation): “After fires that had or could have had serious consequences for lives, health, the environment or property, the municipality shall assess if the preventive work has had the desired effect.”
An unexploited potential for learning
The new regulations may increase the knowledge through fire investigations. That will, however, require that all information from the different investigations is collected in a systematic fashion to be able to extract the knowledge of common interest to increase fire safety in society. Increased fire safety can be obtained through e.g. changes in regulations, development of guidelines or withdrawal of unsafe products from the market. Weaknesses connected to products may represent a fire hazard leading to a fast fire spread or hamper the intended function of fire barriers. If this is revealed through a fire investigation, the industry should be encouraged to product development to find better solutions.
To be able to learn from fires the quality of the investigation work is of crucial importance and we believe there is a need to ensure a certain level of expertise amongst the fire investigators. Our opinion is that some sort of certification scheme for fire investigators would be useful, where one has to demonstrate both theoretical and practical competence to be certified as a fire investigator. Today, there are no criteria for fire investigators in Norway, neither related to education nor experience. Additionally, for larger incidents, we would envision an expert group which could do thorough fire investigations, and transfer learning points to the local and central authorities, fire service and industry. This group could be organised in a similar fashion as the Norwegian Accident Investigation Board, which investigates only transportation-related accidents. Such groups are already seen in other countries, for instance in Sweden, where the Swedish Accident Investigation Authority have the mandate to investigate fires with multiple fatalities, severe damage to property or the environment, or if there has been a risk of potential serious accidents.
A scientific approach
Although SP Fire Research has no general mandate to investigate fires, we have gained extensive experience with fire investigations of different kinds of fire incidents by assisting authorities, industry and insurance companies. We perform projects that involve assessments of police investigation reports and other types of documentation, and also tasks where inspection of the fire scene is an important part of the investigation. In some cases literature studies and fire tests in the laboratory are used to elucidate problems and theories. In other words we have a scientific approach to fire investigation. By combining existing knowledge from other research institutions with laboratory tests we can reject some hypotheses and substantiate others, and in that way come to strong conclusions. We also involve expertise from other specific areas when that is necessary, and collaboration with the fire service and the police is an important part in many cases.
A case study
The methodology applied for all these types of fire investigation cases is the same. Fire investigations require a systematic and traceable approach, and in 2015 we developed a report for the Norwegian Directorate for Civil Protection (DSB) describing a generic procedure for investigation of fire incidents (“Metode for evaluering av branner”, in Norwegian). The procedure can be used as a tool for fire brigades and other parties that are involved in this kind of work to ensure the quality of the investigate.
This methodology was recently applied to a case where a large industrial building with an area of approximately 15 000 m2 burnt to the ground. The building was located some 5 km east of Tønsberg city centre, in the south of Norway. The fire broke out at noon on July 23rd 2015. Although several hundred millions Norwegian Kroner worth of property was lost in the fire, there were no fatalities or injuries. The police’s investigation was focused on finding the cause of the fire, but no clear fire origin or fire cause could be determined – mainly because of the large damage extent. Our mandate was to assess how and why the fire could develop into such a devastating outcome as it did, and to find lessons to be learnt from the incident. We mainly focused on the state of passive and active fire-preventive measures and organisational measures, to analyse if and how these could have affected the outcome of the incident.
The work revealed what may be called many serious and censurable circumstances concerning the organisational fire-preventive efforts in the building, as these efforts seemed to lack altogether. This has resulted in numerous nonconformities with several regulations regarding health, safety and environment – including fire safety regulations. Several passive- and active fire measures did not work as intended either because of poor maintenance or because their function was impeded by numerous minor reconstructions in the building over the years. Some examples of this are a disabled sprinkler system and several punctured fire walls, that both were assessed to have contributed directly to the catastrophic outcome.
Based on this investigation, we identified five learning points which the Norwegian fire brigades, authorities and society should take notice of and incorporate in order to prevent similar incidents from occurring in the future.
We believe, as demonstrated in this case, that investigation of fire incidents represent an unexploited potential for learning. With a relatively modest effort, information and knowledge can be collected for the benefit of the society. It requires, however, not only initiative and funding from the authorities. There is also a need for a system for exchange of experience, which will make sure that the knowledge extracted from investigations of fires systematically will be disseminated to relevant actors. This would ensure that important knowledge is fed back to legislative authorities so that proper legislative amendments could be made, and that efforts can be made to develop relevant information for different target groups.
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