Failure of Incident Ground Communications at 3rd Alarm Chemical Spill in the Waikato
Alan Thompson made this Official Information request to Fire and Emergency New Zealand
The request was successful.
From: Alan Thompson
Official Information Act Request – Incident Ground Communication Issues Waikato
Background to this OIA Request
The NZ Fire service and the NRFA have embarked upon a strategy to introduce incompatible Incident Ground Communications (IGC) within the urban fire services and between the urban and rural fire services.
Prior to 2015 this strategy was ad hoc and urban fire regions decided on a local basis as to whether they would use VHF or UHF for IGC. Beginning with the Waikato area in early 2015 this strategy became formalised as a result of the decision by NZ Fire Service to prefer UHF for urban brigades. Waikato was used as a pilot to tender for and purchase UHF handheld radio equipment for the Paid city brigades of Hamilton. Some $2 million of new UHF radios were delivered to Hamilton around mid 2015.
The high risk of this strategy of introducing nationwide incompatibility in IGC radio equipment has been raised by the writer with the NZ Fire Service and the NRFA. The strategy to adopt Dual Band radios, carry two radios and/or introduce Cross Band Repeating to try to resolve this incompatibility problem and provide some inter-operability capability has also been identified by the writer as flawed and a serious H&S risk to fire fighters. The Hamilton 2015 IGC replacement included some dual band radios that could operate on either UHF or VHF to provide inter-operability with volunteer brigades outside of Hamilton City.
On the 24th of September 2015 a road accident involving as serious chemical spill occurred in the Waikato. A formal operational review of this 3rd Alarm level incident identified operational failures at every level of the response. Central to the Command and Control problems was the lack of reliable radio communications.
The incident occurred in a location where LMR and Cellph reception was very poor. There are many such locations throughout NZ and these are a fact of life for our emergency services.
More significantly the operational review identified that in the early stages of the incident the additional Hamilton City resources arriving at the Safe Forward Point were unable to communicate with the Incident Controller using Incident Ground Communications.
The IC was on the 1st arriving appliance, a volunteer truck from Cambridge. The incident was at a location where it was known that the LMR (and Cell Phones) were unreliable. The operational review report further identified that communications were initially unable to be established using Incident Ground Communication radios. This was in spite of the two locations being less than 500 metres apart in “line of sight”, this being well within the capability of 5-7km that IGC radios can operate “line of sight”.
The operational report identified this very significant failure (of IGC) and the serious problems and risks that resulted as a consequence. The report identified the reasons the LMR (and Cell Phone) communications did not work but made no attempt to identify the reasons for the unusual failure of IGC or recommend any action to address this matter.
The communications issues and in particular Incident Ground Communications placed the lives of responders and others at serious risk and was a major contributing factor in the many failings in the response to this incident documented in the report.
OIA Information Request
Under the provisions of the OIA I request the following information from the NZ Fire Service:
1. Confirmation that the Paid brigades of the NZ Fire Service brigades located in Hamilton and who responded to this chemical spill incident in September 2015 were equipped with UHF incident ground radios as their primary IGC capability.
2. Confirmation that the Cambridge volunteer brigade who were the first response/arrival and their OIC was the IC for the incident were equipped with and used VHF IGC radios.
3. Any notes, reports, emails and other documentation prepared during the operational review that addressed and identified the reasons why IGC radio communications could not be established with the IC located at the incident location and the following arrivals who were at the SFP (a very short distance away and in line of sight).
This should include any such records confirm that the IGC communications problems were a result of the arriving appliances trying to contact CAMB441 using UHF IGC radios that were incompatible with the Volunteer’s VHF IGC radios.
4. After some hours of confusion and delay communication were established from the SFP and the IC at CAM441. I request any information specific to IGC that identifies how this communication was subsequently established (eg on VHF ESB, UHF ESB, local Repeater, etc).
Alan Thompson
Lower Hutt
From: Robinson, Louise
Dear Alan
Please find attached a letter acknowledging receipt of your information request received today.
Kind regards
Louise
Louise Robinson
Business Services Coordinator to Leigh Deuchars, acting Director Office of the Chief Executive
______________________________
New Zealand Fire Service
Phone: (04) 496 3694 or Extn: 4694
Mobile: (021) 833 640
Fax: (04) 496 3700
Email: [email address]
National Headquarters, Level 12, 80 The Terrace
PO Box 2133, Wellington 6140
__________________________________________--
Te Manatū o ngā ratonga ohotata kia haumaru ake ai a Aotearoa │Leading integrated fire and emergency services for a safer New Zealand
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From: Robinson, Louise
Dear Alan
Please find attached a response from Leigh Deuchars, acting Director,
Office of the Chief Executive to your official information request
received on 2 November 2016.
Kind regards
Louise
[1]New-Zealand-Fire-Service-(NZFS)_FULLCOLOUR_small.jpgLouise Robinson
Business Services Coordinator to Leigh Deuchars, acting Director Office of
the Chief Executive
______________________________
New Zealand Fire Service
Phone: (04) 496 3694 or Extn: 4694
Mobile: (021) 833 640
Fax: (04) 496 3700
Email: [2][email address]
National Headquarters, Level 12, 80 The Terrace
PO Box 2133, Wellington 6140
__________________________________________
Te Manat¨± o ng¨¡ ratonga ohotata kia haumaru ake ai a Aotearoa ©¦Leading
integrated fire and emergency services for a safer New Zealand
[3][IMG] [4][IMG] [5][IMG] [6][IMG] [7][IMG] [8][IMG]
Leading integrated fire and emergency services for a safer New Zealand ¦
Te Manatu o nga ratonga ohotata kia haumaru ake ai a Aotearoa
--------------------------------------------------------------------------------------------------------------------
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From: Alan Thompson
1st December 2016
Leigh Deuchars
Acting Director
Office of the Chief Executive
By Email: [email address]
Dear Leigh,
Thank you for the response to my OIA Request regarding communications problems at the Waikato Chemical Spill.
I am a little unsure with respect to the information you have provided as it does not seem to be consistent with the review report of this incident. I seek your further advice and clarification of your response.
With regard to the information I raised with respect to IGC communications you advised that I was incorrect to assume there were radio communications difficulties. Your advice was:
“The NZFS does not hold any documents that specifically relate to this query, perhaps because the question assumes that radio communications could not be established which is incorrect. An (sic) IGC radio link was established on the VHF band between the OICs at the first safe forward point and the incident ground”
and:
“References in the operational review to communications challenges were not related to an ability to establish a working radio link. Rather, they related to challenges arising from radio, as opposed to face to face communications”.
Your advice does seem to be contrary to the review report which states:
1. “The incident was located in an area that had poor radio and mobile phone coverage. These communication difficulties significantly affected the way the incident was managed by responding crews. One consequence of the communication limitations was CAMB441 being isolated at the scene for the first two hours on the southern approach to the incident. (Page 5)
2. “At 00:49 hrs HAMI4118, PUKE431 and HAMI4129 were stopped by the Police at the intersection of Tirau and Kentucky Road. The Police officer advised that he was feeling unwell after inhaling “chlorine-type” vapour and when OIC HAMI4118 exited the appliance he immediately detected a chemical smell. He could see the lights of CAMB441 approximately 500 m further along the road. He decided not to proceed any further and attempted to contact the IC by radio without success. (Page 9)
3. “IGC radio communication between Cambridge and Hamilton appliances was ineffective. This created safety issues and initially affected the management of the incident”. (Page 29 Our findings -Communications)
4. “On arrival at the accident scene, HAMI4118 was set up as the command unit in an attempt to improve radio communication”. (Page 29: Our findings - Command Unit)
5. “Communication difficulties meant that the SSO could not get a full appraisal of the situation and did not attempt to relocate to ascertain what was happening at the incident or request additional resources attend from a safe direction or location”. (Page 36 - Conclusions)
I suggest that the review report clearly identifies that there were radio communication difficulties with both the LMR and with IGC (refer the extracts from the review in 1-5 above).
I seek your further confirmation that the statements in the review report do not relate to any technical issues in establishing IGC radio communications. Ie, they only related to operating or C&C issued as you describe in your response.
In the event that you confirm there was no IGC radio communication issue I would like to suggest that the review report be withdrawn and re-written to:
i. Correct and clarify that the “communications” issues referred to related to inadequate incident management and radio operating procedures by the crew of CAMB441 and not to the performance of IGC radio technology.
ii. Clarify that the IGC radio communications were not in any way effected by the “Black Hole” radio communications situation that only impacted on LMR and Cell Phone coverage.
iii. Address and set out what actions are required to correct the “communications” issues that arose through the failure by the CAMB441 crew (incl the IC) to ensure that they properly established and monitored their radio communications for a period of two hours as you have suggested they did not do.
The failure of “communications was clearly a major failing of this incident and contributed to the dangerous situations that arose for Responders. I remain concerned that whatever the IGC problem was, the review report failed to identify why communications were “ineffective” for such an extended period of time and to identify what follow up actions were required to address this issue.
Alan Thompson
Lower Hutt
From: Robinson, Louise
Dear Alan
Thank you for your email.
I will pass onto Leigh who will respond to you in due course.
Kind regards
Louise
-----Original Message-----
From: Alan Thompson [mailto:[FYI request #4875 email]]
Sent: Thursday, 1 December 2016 3:12 p.m.
To: Robinson, Louise
Subject: Re: OIA 2016.2012 Response to request
1st December 2016
Leigh Deuchars
Acting Director
Office of the Chief Executive
By Email: [FYI request #4875 email]
Dear Leigh,
Thank you for the response to my OIA Request regarding communications problems at the Waikato Chemical Spill.
I am a little unsure with respect to the information you have provided as it does not seem to be consistent with the review report of this incident. I seek your further advice and clarification of your response.
With regard to the information I raised with respect to IGC communications you advised that I was incorrect to assume there were radio communications difficulties. Your advice was:
“The NZFS does not hold any documents that specifically relate to this query, perhaps because the question assumes that radio communications could not be established which is incorrect. An (sic) IGC radio link was established on the VHF band between the OICs at the first safe forward point and the incident ground”
and:
“References in the operational review to communications challenges were not related to an ability to establish a working radio link. Rather, they related to challenges arising from radio, as opposed to face to face communications”.
Your advice does seem to be contrary to the review report which states:
1. “The incident was located in an area that had poor radio and mobile phone coverage. These communication difficulties significantly affected the way the incident was managed by responding crews. One consequence of the communication limitations was CAMB441 being isolated at the scene for the first two hours on the southern approach to the incident. (Page 5)
2. “At 00:49 hrs HAMI4118, PUKE431 and HAMI4129 were stopped by the Police at the intersection of Tirau and Kentucky Road. The Police officer advised that he was feeling unwell after inhaling “chlorine-type” vapour and when OIC HAMI4118 exited the appliance he immediately detected a chemical smell. He could see the lights of CAMB441 approximately 500 m further along the road. He decided not to proceed any further and attempted to contact the IC by radio without success. (Page 9)
3. “IGC radio communication between Cambridge and Hamilton appliances was ineffective. This created safety issues and initially affected the management of the incident”. (Page 29 Our findings -Communications)
4. “On arrival at the accident scene, HAMI4118 was set up as the command unit in an attempt to improve radio communication”. (Page 29: Our findings - Command Unit)
5. “Communication difficulties meant that the SSO could not get a full appraisal of the situation and did not attempt to relocate to ascertain what was happening at the incident or request additional resources attend from a safe direction or location”. (Page 36 - Conclusions)
I suggest that the review report clearly identifies that there were radio communication difficulties with both the LMR and with IGC (refer the extracts from the review in 1-5 above).
I seek your further confirmation that the statements in the review report do not relate to any technical issues in establishing IGC radio communications. Ie, they only related to operating or C&C issued as you describe in your response.
In the event that you confirm there was no IGC radio communication issue I would like to suggest that the review report be withdrawn and re-written to:
i. Correct and clarify that the “communications” issues referred to related to inadequate incident management and radio operating procedures by the crew of CAMB441 and not to the performance of IGC radio technology.
ii. Clarify that the IGC radio communications were not in any way effected by the “Black Hole” radio communications situation that only impacted on LMR and Cell Phone coverage.
iii. Address and set out what actions are required to correct the “communications” issues that arose through the failure by the CAMB441 crew (incl the IC) to ensure that they properly established and monitored their radio communications for a period of two hours as you have suggested they did not do.
The failure of “communications was clearly a major failing of this incident and contributed to the dangerous situations that arose for Responders. I remain concerned that whatever the IGC problem was, the review report failed to identify why communications were “ineffective” for such an extended period of time and to identify what follow up actions were required to address this issue.
Alan Thompson
Lower Hutt
-----Original Message-----
Dear Alan
Please find attached a response from Leigh Deuchars, acting Director, Office of the Chief Executive to your official information request received on 2 November 2016.
Kind regards
Louise
[1]New-Zealand-Fire-Service-(NZFS)_FULLCOLOUR_small.jpgLouise Robinson Business Services Coordinator to Leigh Deuchars, acting Director Office of the Chief Executive
______________________________
New Zealand Fire Service
Phone: (04) 496 3694 or Extn: 4694
Mobile: (021) 833 640
Fax: (04) 496 3700
Email: [2][email address]
National Headquarters, Level 12, 80 The Terrace
PO Box 2133, Wellington 6140
__________________________________________
Te Manat¨± o ng¨¡ ratonga ohotata kia haumaru ake ai a Aotearoa ©¦Leading integrated fire and emergency services for a safer New Zealand
[3][IMG] [4][IMG] [5][IMG] [6][IMG] [7][IMG] [8][IMG]
Leading integrated fire and emergency services for a safer New Zealand ¦ Te Manatu o nga ratonga ohotata kia haumaru ake ai a Aotearoa
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From: Morgan, Tracey
Hello Mr Thompson
Please find attached our response to your request for information
Kind regards,
Tracey
[1]New-Zealand-Fire-Service-(NZFS)_FULLCOLOUR_small.jpgTracey Morgan
Executive & Ministerial Services Coordinator
_____________________________
New Zealand Fire Service
DDI: (04) 496 3641
Mobile: (027) 406 6905
Fax: (04) 496 3700
Email: [2][email address]
National Headquarters, Level 12, 80 The Terrace
PO Box 2133, Wellington 6140
__________________________________________
Te Manat¨± o ng¨¡ ratonga ohotata kia haumaru ake ai a Aotearoa ©¦Leading
integrated fire and emergency services for a safer New Zealand
[3][IMG] [4][IMG] [5][IMG] [6][IMG] [7][IMG] [8][IMG]
Leading integrated fire and emergency services for a safer New Zealand ¦
Te Manatu o nga ratonga ohotata kia haumaru ake ai a Aotearoa
--------------------------------------------------------------------------------------------------------------------
Notice: This email and any attachments may contain information that is
confidential or the subject of legal privilege. If you received it in
error:
1. Please let us know immediately by return email and then delete the
email and your reply.
2. You must not use, copy or disclose any of the information contained in
this email.
There is no warranty that this email is error or virus free.
If this is a private communication, it does not represent the views of the
organisation.
References
Visible links
2. mailto:[email address]
3. http://www.facebook.com/newzealandfirese...
4. http://www.youtube.com/thenzfs
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7. http://www.linkedin.com/company/new-zeal...
8. http://www.fire.org.nz/
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From: Alan Thompson
3rd January 2017
Leigh Deuchars
Acting Director
Office of the Chief Executive
By Email: [email address]
Dear Leigh,
Thank you for the letter dated 21 December 2016 re my request for clarification of the response provided to my OIA Request regarding communications problems at the Waikato Chemical Spill.
1. I note that you have not provided the confirmation requested that the statements in the review report do not relate to any technical issues (radio inter-operability) that prevented effective IGC radio communications.
2. You have advised that the report will be reviewed and refined to clarify the matter that I raised and that a copy will be provided to me.
As previously advised, I would like to stress the importance of also identifying and addressing the issues that caused the communications problems to arise. The report states that the incident location was known to have poor “radio and cellular coverage”. This issue however only impacts LMR radio and should have little/no impact on Incident Ground (IGC) communications. In my opinion the report also currently fails to:
a. Differentiate between radio communications relating to Alerting and Dispatch (LMR) and those that are Incident Ground (IGC). Ie the LMR communications with the Comms Centre versus the Command and Control communications on the incident ground (ie primarily IGC radio).
b. Separately identify and address the problems that were LMR related versus those that were IGC related. Eg an LMR or Cellular “black hole” not impacting on IGC communications.
c. Determine and recommend what needs to be addressed in SOPs and/or training to avoid these same issues happening again.
The significant failings in IGC clearly were a major contributing factor in this incident response and placed NZ Fire Service personnel, other emergency service responders and the public at serious risk. I remain concerned that the Operational Review Team submitted a report that failed to fully identify and address the failings of IGC. I am surprised that the report’s Sponsor and the National Commander accepted this report with such a significant omission.
I look forward to receiving an updated report that identifies exactly what the IGC communications failings were and in particular, what the NZ Fire Service will do to address the issues.
Alan Thompson
Lower Hutt
From: Morgan, Tracey
Hello
NHQ is closed for a Summer Holiday, I will be back on 4 January and will
respond to your email then.
Merry Christmas and Happy New Year
Tracey
[1][IMG] [2][IMG] [3][IMG] [4][IMG] [5][IMG] [6][IMG]
Leading integrated fire and emergency services for a safer New Zealand ¦
Te Manatu o nga ratonga ohotata kia haumaru ake ai a Aotearoa
--------------------------------------------------------------------------------------------------------------------
Notice: This email and any attachments may contain information that is
confidential or the subject of legal privilege. If you received it in
error:
1. Please let us know immediately by return email and then delete the
email and your reply.
2. You must not use, copy or disclose any of the information contained in
this email.
There is no warranty that this email is error or virus free.
If this is a private communication, it does not represent the views of the
organisation.
References
Visible links
1. http://www.facebook.com/newzealandfirese...
2. http://www.youtube.com/thenzfs
3. http://www.twitter.com/nzfireservice
4. http://www.instagram.com/nzfireservice
5. http://www.linkedin.com/company/new-zeal...
6. http://www.fire.org.nz/
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Things to do with this request
- Add an annotation (to help the requester or others)
- Download a zip file of all correspondence
Alan Thompson left an annotation ()
I have kept this OIA Request open as NZ Fire had not completed the action they agreed to undertake. This was to review and re-write the report of this incident to identify and explain the issue that was identified (and the subject of the Request) around why the Incident Ground Communications (IGC) failed. This failure put the health and safety of responding fire fighters, other emergency workers and some members of the public at serious risk. The report failed to identify why IGC failed or what action was required to prevent this problem re-occuring.
It has now been over 4 months since NZ Fire undertook to review this report, correct it and re-issue it they have not completed this work. I have sent two further email requests in this regard and pointed out that this is a significant H&S matter that they should be acting upon.
I will close the OIA status as complete as technically they did provide the information requested. I note however that they have (4 months later) failed to take the action this matter required,
Link to this