OIA15955 Appendix Two RELEASE.pdf

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Contents
Investigation analysis .............................................................................................................................. 5
Investigation findings ............................................................................................................................ 10
Causation analysis ................................................................................................................................. 18
Recommended Corrective Actions ....................................................................................................... 20
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Investigation summary ......................................................................................................................... 21

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Investigation analysis
The below are factors that contributed to the event as part of the ICAM investigation process.
PEEPO information gathering
People
•  FENZ operational personnel staff
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o  Firefighter A is a SF with over 5 years' experience (start date 5/2/2018)
o  Firefighter B is a QF with over 2 years' experience (start date 7/4/2021)
o  Firefighter C is a SF with over 12 years' experience (start date 28/2/2011)
o  The OIC is an SSO with over 23 years' experience (start date 10/4/2000)
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•  Handley industry staff- 9(2)(a)

•  9(2)(a)

•  9(2)(a)

•  Emotionally charged situation

Equipment
•  Breathing Apparatus (BA)
•  Supplementary BA set
•  Appropriate equipment (EASE)
•
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Merlin Entry Control board ECO board
•  Fall arrest equipment
•  Gas detector
•  IGC radios
•  BA lamps
•  Fork Truck with pallet
•  Venting (BA) cylinder
PPE
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•  Level 1 PPE
•  Level 2 PPE
•  The M1-TM Command and Control technical manual, sec 3.7 Snap Rescue, allows for variations in PPE
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appropriate to the risk. The decision was based on enabling freedom of movement in the confined
space of the vat.
Environment
•  Handley industries plant area
•
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Potentially flammable vapours from a variety of substances
•  Vat used for mixing chemicals,
•  Mechanical mixer blades at bottom of vat
•  Portal access/exit 550-600 mm diameter
•  Portal approx. 3m high
•  No mechanical advantage (haulage)
•  Face to face communications
•  Time critical
•  Noise
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•  Confined Space
•  Working at heights
•  Very limited visibility inside the vat

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Procedures
Relevant procedures - refer document reviewed section
•  Intercad/medical Safety Officer – People
•  Safety Officer – People
•  C&C (M1 TM)
o  Situational awareness/size up
o  SPC/DRA
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o  Hazard identification
o  Information streams
o  Planning for escalation
o  3.1.14 Risk Assessment
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o  3.7 Snap Rescue
o  Greater Alarm
•  E3-2-RG Respiratory Protection Equipment-Reference Guide
o  Emergency Team
o  Air Management
o  ECO
o  BA wearer
o  Relief team availability
•  IS1 – Incident ground safety
•  ISIS6- Exposure standards
•  G7 POP Decontamination and G7 SOP Decontamination
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•  Working at heights
•  PPE
Section 36 (3)(f) of the Health and Safety at Work Act requires the provision of information, training,
instruction & supervision necessary to protect workers from risks to their health and safety. The
following procedures do not contain all the elements of WorkSafe’s latest guidance - Confined spaces:
planning entry and working safely in a confined space March 2020 (based on AS2865 Confined spaces)
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including but not limited to significant hazards -noise, WAH, moving machinery, psychological
hazards. Control measures to decommission moving parts e.g., augers/mixers/agitators/conveyor
belts. Procedures should also be aligned with the current FENZ SHW critical risks: -
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Organisation
Decontamination
Training – As at the date of the incident, 22/8/23 9(2)(a)
were current on
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the required training relevant to this incident (refer to Takapuna snap rescue SHW L2 Investigation -
Records of relevant Training): -
Communications, Equipment, Hazardous Materials, Incident Management, Medical, Rescue,
Respiratory Protection, Recertifications and SHW (Safe Person Concept) 9(2)(a)


OSM shows 9(2)(a)

Post incidents actions
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Scene examinations, photographs, sketches, plans and attachments
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Image 1 Map of the premises of Handley Industries, Hillside Road Auckland, and surrounding
buildings.
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Image 2 Inside the Handley Industries plant room area factory, the blue mixer vat in the middle was
the scene of the rescue.
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Image 3 Close up of the 3000-litre mixer vat.

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Image 4 Looking down from the top portal into the interior of the vat showing the mixing paddles at
the bottom of vat, residue of ‘dry’ chemicals on the walls of the vat and the very confined space the
Firefighters had to carry out the rescue in.
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Image 5 The top of the mixing vat showing the portal which measures approximately 600mm in
diameter and the only point of entry/egress. It was not wide enough for a Firefighter to enter
wearing BA on their back, so the BA had to be doffed and passed through entry hatch, as per
restricted space procedures.

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Investigation findings
Witness interviews
The names of the people who witnessed the event and were interviewed as part of the investigation.
•  Crews of Takapuna 807 and Birkenhead 821 in a debrief session
•  SSO and Firefighter A in a follow up session
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•  9(2)(a)

Documents reviewed
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Documents reviewed as part of the investigation process:
Internal - FENZ
M1 TM Command and Control Technical Manual - January 2013 - Snap rescue in command and
control. (Under review)
H1 TM Hazardous materials technical manual – September 2015 - 5 yearly review (under review,
early stages of update)
S3 Confined spaces (NCI 34) - Dec 08 (last updated 28/4/2017 on portal) “When working in confined
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spaces, NZFS personnel will also refer to: E6-2 POP Gas detectors” page 1
Specialist Knowledge Confined Space (S3) OSM – (last updated 28/4/2017 on Portal) Operational
Skills Maintenance – a knowledge check for “The Firefighter demonstrates knowledge of confined
spaces” with 3 questions and answers and a sign off sheet
Specialist knowledge BA Confined Space wearing – OSM – (last updated 28/4/2017 on Portal,
document amended October 2015) a knowledge check for “The firefighter explains the use of
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breathing apparatus in a confined space” – 11 questions and answers and a sign off
QFC-2-15 Confined Space rescue (last updated 28/4/2017 on Portal). QFF programme, Study guide
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fifteen. The theory component contains this Study Guide, the workbook, and an assignment.
Requires practical training and a consolidation period to assist in a confined space rescue and this
task must be performed at least twice during the consolidation period.
E3-2-RG Respiratory Protection Equipment-Reference Guide.
Near Miss Initiative – Working with Hazardous Substances 4/4/2023 published on Portal 29/3/2023
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by the Safety, Health, and Wellbeing team - An example of a near miss involving working with
hazardous substances responding to an event at a school swimming pool, Ambulance Officers
conducting their patient survey and care in a confined space with cross-contamination causing them
to feel unwell including psychosomatic symptoms.
E6-2- 1 POP Multi Gas detectors policy – 26/8/2022 - This policy sets out the rules that apply to
trained Fire and Emergency New Zealand (firefighters) who use multi-gas detectors (MGDs). Includes
but is not limited to …  “All confined space operations including Urban Search and Rescue (USAR)”.
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The aim of this policy is to protect Fire and Emergency personnel from dangerous gases or
atmospheres during operations and investigations. Learning station references below: -

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FENZ Safety Health and Wellbeing Manual – section 6: Risk Management
FENZ Risk Management Standard – 20/3/2023
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M1 TM - Safe Person concept and Dynamic risk assessment (3.1.14) (3.5.1)
M1 TM – Acceptable risk (3.5.9)
M1 TM - Command system (1.5.1)
M1 TM – Snap rescue (3.7)

External References:
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Health and Safety at Work Act 2015: -
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Part 1 sec 22 Meaning of Reasonably Practicable
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Part 2 sec 30 Management of Risks
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Part 2 sec 36 Duties of PCBU’s - Primary Duty of Care
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Regulations 212 Regulations relating to hazardous substances
Hazardous Substances and New Organisms Act 1996
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WorkSafe NZ Quick Guide – “Confined spaces: planning entry and working safely in a confined
space” March 2020 - A brief overview of the requirements and procedures of AS 2865
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AS (Australian Standard) 2865/2009 Confined spaces is the standard that sets out the minimum
requirements and risk control measures for the safety of persons entering or conducting tasks in or
on a confined space. The Standard is referred to in S3 Confined spaces (NCI 34).
NZQA Unit standards
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Fire and Rescue services – Structural and industrial - Level 4 -14562 Perform specialist rescues in
confined spaces
Occupational Health and safety Practice - Level 3 – 18426 Demonstrate unit knowledge of hazards
associated with confined spaces. Level 4 – 17599 Plan a confined space entry

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Full description of the event
The Takapuna 807 (TAKA807) crew were called to a medical incident just after 1130hrs on the 22nd
of August 2023. The information passed to the crew on turnout was that 9(2)(a)

at Handley Industries, 77F Hillside Road, Takapuna.
The incident was approximately 1.2km from the fire station and an estimated three-minute drive
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(Google), TAKA807 were alerted at 1133hrs, submitted a K1 at 1135 hrs and arrived at the incident
‘K55’ at 1137 hrs, a total time of alert to arrival of approximately four minutes.
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On arrival the crew expecting and prepared for a 9(2)(a)

  They were now presented with a 9(2)(a)
entrapment within a chemical mixing vat, 9(2)(a)


The vat was located on a support frame with a top entry hatch, access on the top of the vat which
was normally reached by the business’s portable scaffold frame. The vat was a 3000-litre round tank
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with a central mixing arm, therefore giving a restricted 3 cubic metres of space inside the vessel. The
vat was used to mix paint brush cleaner containing Toluene (UN 1294) Methyl isobutyl ketone (UN
1245) and Ethanol (UN 1171) and was last used 24 hours prior to incident. The 9(2)(a) from Handley
industries, when asked about what chemicals were in the vat, advised it was a household product
that you could buy at Bunnings, and it was only fumes. One of the firefighters advised the multi-gas
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detector was set up for methane and it was presumed the vat was low in oxygen, they didn't think
the multi-gas detector would have picked up anything like Toluene and they would have needed a
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photo-ionisation detector (PID) set to the specific chemical to give valid intelligence, this was not a
readily  available resource. It was also considered that noise from the alarm on the multi gas
detector would not be beneficial, as it wouldn’t provide them any additional intel, working in an
environment (low oxygen) that would set the alarm off. Once the rescues were carried out the MSDS
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were reviewed, which confirmed the identity of the chemical. The rescues were time critical due to
9(2)(a)

A valve was opened at the bottom of the vat and a compressor at the premises was used to push air
into the vat early on (approx. 40 litres). When asked if this made much difference, a Firefighter
advised it was “like a hairdryer close to you”.  It should be noted that the usual procedure for the
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organisation was to ventilate the vat for 3 days after mixing chemicals, before workers were
authorised to enter the vat for cleaning. However, in this case, 9(2)(a)

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9(2)(a)

The officer in charge (OIC) was required to undertake a rapid mindset change from the expected
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routine purple event they were responded to and expecting, to a highly technical, snap rescue
operation, 9(2)(a)
  At 11:41, the Communications Centre asked, “Do you  ACT
require any further resources?” the OIC recognised the need for additional assistance to perform the
rescue and upgraded the incident by making pumps 2 for further resource.  The OIC undertook a
rapid scene assessment (size up) gathering information from observation (no HAZCHEM notices
where visible at this entrance to the business) and an interview with the 9(2)(a)
who was
present. Based on the limited information at hand, the OIC’ formed a plan to undertake a snap
rescue and whilst he was very aware of the high-risk factors involved, 9(2)(a)

.  Birkenhead 821 arrived at 11:45 hrs
(approximately 4 minutes response time) and the OIC discussed the plan with the second arriving
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officer and confirmed the course of action.
The critical risks presented were:
1.  Working in a confined space - with low visibility, access/egress difficulties, physical
exhaustion, high ambient temperature and moving mechanical parts.
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2.  Working at heights - (between 3 and 4 metres off ground)
3.  Working in an irrespirable (toxic) atmosphere
4.  Working in or around flammable materials
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5.  Psychological Hazards –
6.  During the incident: - potential for anxiety, panic, or claustrophobia/
7.  Post incident: - psychological trauma.
8.  Fatigue – associated with sustained or prolonged physical and cognitive effort.
9.  Noise - acoustics /echo within the Vat, volume and pitch emitted from ADSU.

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Both Crew members from 807 donned breathing apparatus (BA), only Firefighter A (due to restricted
working space) was directed to enter the vat and conduct the rescue. The firefighter inside the vat
utilised the appliances working at heights safety harness to attach to 9(2)(a)

, two firefighters positioned on top of the vat assisted with the

9(2)(a)
The OIC retained the safety officer responsibilities due to the close nature of the command
point to the operations and his awareness of the hazards. The business’s forklift was utilised with a
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wooden pallet placed onto the forks and then raised to the level to the top of the vat, to increase
the working area available to FENZ staff on top of vat.  There was insufficient distance between the

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top of the vat and the roof of the building, to utilise the mechanical lift capability of the forklift or for
it to be used as an anchor point for fall arrest equipment, both these options were considered by the
OIC. 9(2)(a)

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second firefighter ‘firefighter B’ in BA made entry to the vat to assist with the second rescue and the
two firefighters
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9(2)(a)

Firefighter A who had made the initial entry noted his air-supply was getting low, this was also  ACT
identified by ECO and the OIC had arranged the provision of a relief BA set, to provide a backup air
supply. Entry Control was operating a telemetry board and had all relevant tallies entered. It was
identified by the crew conducting the rescue that the 9(2)(a)

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The backup BA set had not made it into the vat when 9(2)(a)

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9(2)(a)

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  Ambulance queried the need for decontamination and was informed by the OIC that it
was not required; this decision was based on the information gathered from the 9(2)(a)

The crews followed standard procedures and ‘bagged and tagged PPE’ for cleaning, no
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personal decontamination was instigated for the firefighters. 9(2)(a)

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9(2)(a)

Post event response
9(2)(a)

9(2)(g)(i)

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BA sets from the incident were impounded for investigation. 9(2)(a)


Investigation findings
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1.  Our finding is that the SSO’s decision to proceed with the snap recue was justified given the
dynamic risk assessment of this very complex incident.
The OIC made a series of effective decisions when presented with an unexpected critical
situation, with very little verified information and time pressure to conduct a rescue. The
tactical choices open were at the extreme end of the scale but given the time available to
conduct the snap recue, the choice to proceed was reasonable to 9(2)(a)

and the hazards present were managed as best they could be given the working
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environment.
2.  Our finding is that Firefighter A made a conscious, individual decision based on a reasonable
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expectation, to work into the prescribed safety margins of his BA to affect a rescue for a
9(2)(a)
  However, this decision breached the E3-2-RG Respiratory Protection
Equipment-Reference Guide, Air Management, page 33.
The firefighter underestimated the duration of their remaining air supply 9(2)(a)

considerably slowing the
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rescue activity, and increasing the firefighters’ workload, consequently increasing the air
consumption rate. This, along with the arduous conditions resulted in an unexpectedly high
air consumption impacting the firefighters’ mental calculations of the remaining air capacity.
This resulted in the firefighter briefly exhausting their air supply before they could exit the
vat to fresh air. 9(2)(a)

3.  Our finding is that no procedure exists for the situation of a firefighter completely
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exhausting air supply, an ad hoc attempt at sharing air with firefighter B via sharing of LDV,
was ineffective. FENZ training systems are designed to prevent this situation occurring
however when firefighter A completely exhausted their air supply, there was no procedure
or training to draw upon to manage this situation.

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4.  Our finding is that the dynamic risk assessment made by the OIC considered the flammability
risk and determined that no further control measures would be required, however all
chemicals should be treated as flammable until proven otherwise. The intelligence that the
decision was based on was on the advice of 9(2)(a)
that the chemical was a
household product that you could buy at Bunnings and was not validated by any other
source. Whilst it should be reasonable to assume that the 9(2)(a) knowledge of their
operations and chemicals used is adequate to rely on, other factors can bias advice such as
organisational reputation, complacency, and a possible motivation to ‘play down’ the
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seriousness of the incident.   A dynamic risk assessment should include treating all
flammable materials as being in their explosive range until confirmed otherwise, e.g.,
reviewing the MSDS, atmospheric measurements, technical advice etc.
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5.  Our finding is that the decision to proceed with working at height in the absence of the
normal controls to mitigate the risk, was reasonably justified considering the dynamic risk
assessment - the criticality of time, 9(2)(a)
and the absence of suitable
anchor points in the building. Whilst the working at height risk was identified by the OIC, the
ability to implement control measures such as fall arrest (roof kit) was not practical due to
the lack of anchor points. An attempt to minimise the risk was instigated by raising an empty
pallet on the forks of a forklift to the height of the vat portal, providing a larger working
platform for the exterior crew members. The pallet was also used to transport the
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9(2)(a)
, minimising further heavy physical manual handling
that would have been required to lower them to the ground from the 3m high vat portal.

6.  Our finding is that whilst the Safe@Work report of the incident “Exposure to hazardous or
biological substance” (Event 15580) includes details of firefighter A’s involvement, it does
not contain sufficient details in “What happened”, of the roles of firefighters B and C
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9(2)(a)  or 9(2)(a)  persons”). 9(2)(a)

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7.  9(2)(a)

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8.  Our finding is that confined spaces procedures require review as they do not contain all the
elements of WorkSafe’s latest guidance - Confined spaces: planning entry and working safely
in a confined space March 2020 (based on AS2865 Confined spaces). This includes but is not
limited to significant hazards -noise, WAH, moving machinery, psychological hazards and
control measures to decommission moving parts e.g., augers/mixers/agitators/conveyor
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belts. Procedures should also be aligned with the current FENZ SHW critical risks as they are
not currently all included.

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9. Our finding is that following discussion with the Firefighter Development Manager, the
recruit and qualified firefighter TAPs programmes it was and determined that these training
programmes adequately include both confined space training and an understanding of air
consumption rates under heavy workloads.

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Investigation summary
Lessons learned
Never consider working into the safety margin for any reason whatsoever, always follow the
procedures when the warning whistle activates and entry control indicates exit (time due out) is
required.
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ECO and the OIC must ensure that firefighter whose warning whistle has activated is evacuating the
hazardous atmosphere to safety as a priority.
Priority should be given to confirming the flammability risk via verified intelligence, before
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commencing operations. In the situation where the flammability cannot be determined, then always
treat flammable materials as being in their explosive zone.
All FENZ personnel should be reminded of the facility to report psychological incidents in
Safe@Work.
Procedures and policies should be reviewed on a regular basis to capture best practise to ensure
firefighters are prepared for a safe response.

Other observations
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Whilst out of scope of this investigation, it was identified that the decontamination procedures in
the H1 TM Hazmat Technical manual do not align with the Queensland Fire and Rescue Scientific
Branch on-call Scientific Officer’s advice, which is based on the specific situation and the current
research/best practise. The organisation recognises the current set of procedures is out of date and
the Hazmat Response Capability Development Programme -HRCDP was reviewing this but is
currently on hold. The Decontamination work group is currently reviewing the decontamination
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policy and procedures.
Section 32 (3) (g) of the Health and Safety at Work Act 2015 requires that the health of the workers
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and condition at the workplace are monitored for the purpose of preventing injury or illness.
A rollout of additional gas detectors is planned, they are a personal multi-gas monitor (passive
detector rather than an active detector like the MulitRAE) this means that it doesn't rely on a person
focusing on looking at a monitor. They will provide a personal alarm to alert a firefighter that they
are in a dangerous atmosphere.
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There will be a phased roll out of gas detectors to 50 stations by the end of the financial year,
commencing 1 November 2023. Fire and Emergency own sufficient gas detectors for 115
appliances.

Summary of recommendations
The investigation has recommended three corrective actions. These include a review of procedures
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relating to confined spaces, developing and communicating a Lessons Learned, and raising
awareness of the existing psychological event reporting tools in Safe@Work.

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