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Contents
Executive Summary ................................................................................................................... 3
Findings ...................................................................................................................................... 3
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Recommendations .................................................................................................................... 5
Operational Assurance .............................................................................................................. 5
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Purpose of Review ..................................................................................................................... 5
Methodology ............................................................................................................................. 6
Language .................................................................................................................................... 6
Review requested by ................................................................................................................. 7
Review Team ............................................................................................................................. 7
Links ........................................................................................................................................... 7
The Event ................................................................................................................................... 7
Environment ............................................................................................................................ 13
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Conclusion ............................................................................................................................... 13
Appendix A - Terms of Reference ........................................................................................... 15
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Executive Summary
On 22 August 2023, a purple medical incident was reported at Handley Industries in Wairau
Valley. However, when the crew arrived, they found 9(2)(a)
. Within seconds the
OIC had to quickly change his approach from a routine medical response to a highly technical
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rescue operation. After gaining some situational awareness from his surroundings and
gathering information from the company CEO, he formed a plan to undertake a snap rescue.
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The Birkenhead crew arrived to assist, and both Officers quickly reviewed the plan, confirming
that it was the best option. The crew successfully rescued 9(2)(a)
Findings
The review team found the following:
• The Takapuna SSO start of shift routine of checking the on-duty roster, provided a
component of the “Dynamic Risk Assessment” and “Safe Persons Concept” before the
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incident even occurred. It provided him with the knowledge of the neighbouring officers
and firefighters skillsets that would be available to him in any event that may have occurred
that shift. Knowing this, the SSO knew he had the appropriate personal with the right skills
to achieve a successful outcome at this incident.
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• The OIC's decision to proceed with the snap rescue was validated, given the complex
situation presented to the Takapuna crew upon arrival at the scene. Within seconds of
arriving on scene, the OIC had to change his mindset from a medical event to a technical
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rescue, evaluate the situation and make a series of effective decisions when presented
with an unexpected critical situation. With very little verified information and time pressure
mounting, a snap rescue was the only option 9(2)(a)
. The OIC
considered the vats internal environment, entry point and lack of securing points for
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connecting line equipment. This was overcome by his crew’s wearing BA and a forklift
being used to create a safer working platform at the vessel’s entry hatch.
• 9(2)(a)
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• The crew’s safety, health and wellbeing were a priority for the Assistant Commanders who
attended the incident. 9(2)(a)
•
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9(2)(a)
• The on-call Assistant Commanders were notified of the incident approx. 40 minutes after
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the recorded start time. The rescues had been performed at the time of their arrival and
they felt they would have preferred to have been informed earlier due to the complexities
of this incident type.
• Entries were entered into Fire and Emergency New Zealand safe@work system under the
“exposure to hazardous or biological substances” heading, 9(2)(g)(i)
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• The OIC managed to address most of the issues listed as hazards in S3 Confined Spaces
(NCI 34) procedure during the very short timeframe he had to size-up the scene and create
a plan 9(2)(a)
. However, it is noted that the current procedure is dated December
2008 and doesn’t align with the Worksafe confined spaces, planning entry and working
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safely in a confined space notice, issued March 2020.
• The SMS Incident Report shows that Worksafe (Mahi Haumaru Aotearoa) was notified of
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the incident by the New Zealand Police. This was agreed to on the incident ground
between the OIC and one of the attending Police Officers.
• The BA impounding procedure was implemented at the request of one of the Assistant
Commanders who attended the incident. The sets involved were immediately sent to
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Draeger for analysis. No faults were found. It was noted by a BA SME, that because the
sets were sealed within an airtight plastic bag, it locked in the vapours on the sets which
were then released upon arrival at the Draeger service centre.
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Recommendations
The review team recommend the following:
• A national communication is issued to all operational personnel emphasising the
importance of understanding and training in air management, particularly in arduous
situations where air consumption is higher than usual.
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• The Response Capability team develop a procedure for operational personnel with the
intent of providing guidance in the event of an air supply being exhausted while wearing
BA.
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• Tamaki Makaurau Commanders or Te Hiku Operations Group engage with the Region
Planning and Performance team to adjust the notification triggers for this event type to suit
their requirements.
Outside of the scope of this review however worth highlighting, is the use of BA rapid
intervention kits. These are not a new concept and are commonplace in brigades around the
world. They can be strategically located to enhance response to incidents such as:
o Mayday (Firefighter lost, trapped, running low on air)
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o Confined Space
o Trench Collapse
o Water (person trapped in rising water incidents)
These kits provide an Officer with improved tactical options, enhance safety, and reduce risk
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to our personnel and members of the public.
Operational Assurance
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Fire and Emergency New Zealand Operational Assurance aims to advise the Deputy Chief
Executives of Service Delivery (National Commander) and Service Delivery Design (Deputy
National Commander) to ensure they achieve their responsibilities for the operational
efficiency and readiness of Fire and Emergency New Zealand. The Operational Assurance
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team is required to be independent and objective and provide quality operational assurance
advice to support continuous improvement regarding the organisation.
Purpose of Review
An Operational Review examines how Fire and Emergency New Zealand responded to
substantial, significant, or unusual incidents to enable continuous improvement. While it
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considers the application of policies, procedures, and operational instructions (as they applied
to the event), its primary focus is to assist Officers' and Firefighters' learning by sharing
knowledge and experiences gained through actual incidents.
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A review focuses on the facts and does not provide conjecture or alternative opinions. The
review identifies critical findings to inform senior managers where improvements are needed
or where corrective actions are required. It identifies general findings related to strategy,
tactics, leadership, agency and community engagement and activities that worked well to
support organisational learning.
Few reviews of emergencies, undertaken with the benefit of hindsight, would not identify
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lessons for the future, and this is one of the main reasons to carry out reviews of this nature.
Therefore, our comments and observations should be read in the spirit that they are intended
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to support continual improvement of service delivery to the people of New Zealand.
Methodology
The review team uses the Incident Cause Analysis Method (ICAM) as a guide to conducting
operational reviews.
The content contained within this report reflects the information provided to the team through
debriefs, interviews, and data collected through Fire and Emergency reporting systems.
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Note, that a Fire and Emergency New Zealand login is required to access most links within
this document.
Language
We may use language in this report, such as 'we were told', which sets the context for the
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following conclusions but does not imply that we investigated and confirmed the statement's
truth. We believe that everyone we spoke with engaged with us in good faith, and the very fact
that we were told certain things may indicate a need for discussion and reflection, even if it
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later turns out that what we were told is only a point of view or that there is more to the story.
If we use phrases such as 'we found' or 'we conclude,' these should be taken as conveying
our opinion on the matter based on the best evidence available to us.
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Throughout this report, the Operational Assurance or Investigation team will be called "the
team".
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Review requested by
Deputy National Commander
Brendan Nally
Sponsor
Region Manager/ANC Te Hiku
Ron Devlin
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Review Team
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Manager Operational Assurance
Darryl Papesch
NZPFU Rep
Phil Barrow
Links
F3803300
ICad report
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The Event
22 August 2023 started like any shift for the SSO at Takapuna station. He followed his usual
start-of-shift routine by checking the Station Management System (SMS) rosters to confirm
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which Officers and crews were on duty within his cluster of stations. This provided him an
advantage ahead of any incident, knowing who's on duty and the various strengths and skill
sets within the surrounding team.
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At 11:33 that morning, whilst the crew was doing PT, they received a call to a medical incident
at Handley Industries, 77 Hillside Road, Wairau Valley. The information stated that 9(2)(a)
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(wildfire) jacket and barrier gloves.
A K1 (en route) was transmitted from Takapuna 807 (TAKA807) at 11:35hrs. The address was
approximately 1.2 km from Takapuna Fire Station, and they arrived two minutes later with their
arrival message (K55) transmitted at 11:37hrs. The ambulance also arrived at this time.
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On arrival, the crew was met by a 9(2)(a)
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With the crew geared up for and in a medical response mindset, 9(2)(a)
9(2)(a)
The vat was a 3000-litre upright cylindrical tank with a central mixing arm. It had a
small top entry hatch, approx. 600mm in diameter and approx. three metres above ground
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level. Access to the top of the vat was by a movable stair and platform structure.
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Photo 1 – the vat (blue) that 9(2)(a)
with movable platform in front.
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Photo 2 – small access hatch approximately 600mm in diameter
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9(2)(a)
Further
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questioning confirmed the vat was used to mix various hazardous substances to produce paint
brush cleaner. It was last used 24 hours before the incident and had been venting since then.
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9(2)(a)
The OIC was required to rapidly change his mindset from the expected routine purple event
to a highly technical rescue operation with 9(2)(a)
and minimum timeframe to act, all within a confined space. With the information already
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gathered, the OIC undertook a rapid scene assessment, gathering information from observing
his surroundings and questioning the 9(2)(a)
who was present. Based on the limited
information at hand, the OIC quickly went applied the DRA and SPC processes in his mind,
formed a plan to undertake the rescue, and whilst he was very aware of the high-risk factors
involved, felt that the 9(2)(a)
. His crew
members agreed and didn't hesitate at the mention of performing a snap rescue.
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The OIC tasked his number one and two crew members to remain in their current PPE and
quickly don breathing apparatus. Due to the significantly restricted workspace and size of the
hatch, one firefighter was directed to enter the vat and conduct the rescue. 9(2)(a)
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9(2)(a)
, so he donned his BA mask, doffed his BA set, entered the hatch, then brought his
BA set in after him, placing it on the floor of the vat. The OIC also requested that the "working
at heights safety harness" 9(2)(a)
, although he noted
there was nowhere above the vat to suspend it. The driver established entry control
(telemetry), transmitted messages, and provided equipment as required.
At about this time (11:39), a Sitrep was transmitted from TAKA807, stating there were
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9(2)(a)
firefighters were in BA. Noting the change in
circumstances, the Comcen operator asked if further resources would be required, to which
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the OIC replied, "make pumps two". By pure coincidence, the Birkenhead crew (BIRK821)
was near the incident and arrived approximately three minutes later.
The Birkenhead Officer liaised directly with the OIC, and between them, they re-evaluated
the plan and considered alternative tactics. This second opinion confirmed that they should
proceed with the initial plan due to the time available to reduce the chances of 9(2)(a)
Guidance was sought by ambulance regarding decontamination. The 9(2)(a)
said
this was unnecessary due to the internal walls of the vat being dry, no residue being present,
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and only an irrespirable atmosphere being the risk. The OIC and ambulance agreed, opting
for no decontamination to take place.
With two crews present and the 9(2)(a)
, two firefighters
positioned themselves on top of the vat and 9(2)(a)
. While this
was underway, the OIC asked for the business's forklift with a wooden pallet on the forks to
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be raised to the height of the top of vat, providing a better working platform. 9(2)(a)
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A Sitrep was transmitted from TAKA807 at 11:58, 9(2)(a)
A second firefighter in BA entered the vat to 9(2)(a)
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The firefighter who had made the initial entry noted that his air supply
was getting low, and a relief BA set was requested to provide a backup air supply. The rescue
crew realised the 9(2)(a)
. With everyone positioned to conduct the second rescue, it
was expected to take a similar amount of time as the first one. The backup BA set didn't make
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it into the vat by the time the decision to proceed with the rescue took place. Instead, it was
positioned close by at the base of the movable access platform.
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While all this activity was taking place the Police had arrived, also 9(2)(a)
had redirected a compressor hose with fresh air into the base of the vat via a draining valve.
Furthermore, the environment within the vat was extremely confined, 9(2)(a)
The visibility was poor, and the two
firefighters also had difficulty communicating due to the noise of the compressor air entering
directly below them. Both of their BA sets DSUs had activated because they were motionless
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at the bottom of the vat.
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Photo 3 – the interior of the vat showing the mixing arm and paddles, 9(2)(a)
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At 12:12, GMWAITE01 (Assistant Commander) was notified, followed by GMWAITE05
(Assistant Commander) three minutes later.
9(2)(a)
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9(2)(a)
A Sitrep was transmitted from TAKA807 at 12:17, stating the second rescue had been
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achieved.
A stop message was transmitted from TAKA807 at 13:10.
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When the Assistant Commanders arrived at the scene, they shared the responsibilities
required to be performed. They received a detailed situation briefing from the OIC and liaised
with the other emergencies. From these conversations they confirmed that Worksafe had been
notified by the Police. A phone call was made to the Comcen Operator to provide a detailed
sequence of events and make the appropriate notifications. One of the Assistant Commanders
9(2)(a)
Both Assistant
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Commanders kept the District Commanders informed and fielded phone calls for the rest of
the afternoon.
The total time between Takapuna crew arriving and the Sitrep stating the rescues being
completed was only 40 minutes.
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9(2)(a)
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the third firefighter being the one located near the access hatch
whose task was to have a visual on the people inside, pass equipment, assist with extrication
and be the main point of communication between the crew and OIC. 9(2)(a)
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Environment
The vat was a 3000-litre round tank with a central mixing arm, with an internal volume
restricted to 3 cubic metres. It had a small hatch approximately 600mm in diameter located on
the top. The vat was used to mix products to produce paint brush cleaner that contains
Toluene (1294) Methyl isobutyl ketone (1245) and Ethanol (1171) and was last used 24 hours
before the incident.
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The inside of the vat was dry and didn't have any chemical residue. Usually, the cleaning
process involves the vat being vented for three days before any cleaning takes place. ACT
A movable stair and platform system provides access to all the vats.
Conclusion
The situation at Handley Industries on 22 August 2023 required a rapid shift in mindset from
a routine medical incident to a highly technical rescue operation. The OIC and his crew quickly
assessed the scene and developed a plan to rescue 9(2)(a)
inside a chemical
mixing vat. Despite the high-risk factors involved, the OIC and his crew members performed
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a snap rescue within minutes by donning breathing apparatus and using a working at heights
safety harness 9(2)(a)
. They made the use of facilities within the factory such
as a working platform and a forklift to assist and hasten the rescue. The quick response of the
crew and the coordination with other resources on scene 9(2)(a)
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Appendix A - Terms of Reference
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