1. Hazmat Case Study ‘Barn Fire’ Trevenna Farm St. Neot, Liskeard
Thursday 1st September 1994

2. Introduction
The purpose of this presentation is to share an operational incident that occurred within Cornwall County Fire Brigade which led to the unfortunate death of Leading Firefighter Mike ‘Sonny’ Liston.
Saturday 3rd September 1994
Ask the audience, “what are you visualising in your head, when you think of a barn fire?”. Describe a barn fire?

3. Farm Hazards by UN Class
Class 1 Explosives (firearms & bird scarers)
Class 2 Gases (LPG, Acetylene)
Class 3 Flammable Liquids (Diesel)
Class 4 Flammable Solids (dry manure)
A useful Hazmat refresher to run through the UN Classifications of fire and run through them in context of a farm environment.

4. Farm Hazards by UN Class
Class 5 Oxidising Substances & Organic Peroxides (Sodium nitrite /Ammonium Nitrate)
Class 6 Toxic & Infectious (herbicides)
Class 7 Radioactive (combine harvesters)
Class 8 Corrosive Substances (Sulphuric acid - potato farming)
Class 9 Miscellaneous (Asbestos)
A useful Hazmat refresher to run through the UN Classifications of fire and run through them in context of a farm environment.

5. ‘Turnout’ details Approx 1500hrs, Thursday 1st September 1994
Reported “Barn Fire”, St. Neot, Liskeard
PDA ~ 2 WrL Appliances (711 & 717) ~ 1 Supervisory Officer
711 (WT, crew of 4), 717 (RDS, crew of 6)
Additional information on turnout sheet stated: “Possible chemicals involved”
The duty crew had just returned into the fire station yard after undertaking a fire safety visit and the station turnout system operated as the appliance was turning in the yard.
FF got off the appliance and went to the watch room to get the turnout details. Passed turn out instructions to the Sub O and read out he fact that the message details stated “possible chemicals involved”.
Crew of 4 :
Driver (Firefighter)
I/C Sub O
BA LFf
BA Ff (just completing 2 year probationary phase)
As Ff was in probation with an assessment coming up the LFf posed some Q&A in relation to farm related incidents (Nitrates, fertilisers etc) on route to this incident.

6. Location of Incident
Address was on border of 2 stations in a remote rural location, with an approximate 20 minutes travel time.

7. This photo shows the farm site, and was taken in 2008

8. Wind Direction
At this time the 4 walls of the building (barn) still stands.
The farmhouse is shown just above the building as the first appliance stopped just short of the buildings in the lane

9. On Attendance Met by the farmer (waiting in lane)
IC gathers incident information
“You stated on the call ‘possible chemicals involved’ – what and where are they?” “Anything else?”
As per slide,
Sub O met by farmer to gain incident information and asked direct questions in relation to reference to chemicals being involved.
It was not an intense fire and quite ‘lazy’, as the roof soon collapsed in and provided a smothering effect to the contents

10. Building details “Outbuilding” Measured approximately 8m x 4m
Traditional stone construction
Timber Trusses, Corrugated Tin Roof
Mixed Contents (tool shed / lawnmowers etc)
Bagged Nitrates “not affected” in adjacent lean too.
“Outbuilding”
Could not be described as a barn, as on the turnout details, a “workshop” was more relevant
Measured approx 8m x 4m
Traditional stone construction
Timber Trusses, Corrugated Tin Roof
Mixed Contents (tool shed / lawnmowers etc)
Bagged Nitrates “not affected” in adjacent lean too.
The farmer’s reference to “possible chemicals involved” was concern for these bagged nitrates which were external to the building and under a lean too, and they were clearly not affected or involved.

11. Note, this photo consists of 2 photos of the building joined together.
Note the lean too on the right hand side which was unaffected.

12. Deployment of resources
Hose reel jet used on ‘lean to’ gable end.
2 Breathing apparatus Stage 1, HRJ to extinguish building contents
6 minute lapse before arrival of 2nd appliance. Primary role to supplement water supply from nearest hydrant located approximately 200 metres away.
Self explanatory

13. This photo was taken approximately 4 days after the fire

14. Significant Points How did the fire start?
Fire Extinguished…..heat retained in walls
Breathing apparatus removed, turning over continued
2 Plastic containers identified during turn over phase
How did the fire start?
The Sub O asked questions to how the fire started, and was directed to the farmers son and his friend who were about 10 years of age. They had conflicting stories, to the Sub O spoke to 1, whilst the supervisory spoke to the other. It turned out that they were playing with matches and lit some hay which got out of control inside the building.
Fire Extinguished
BA was worn as there was a need to get in and remove the galvanised roof panels and it did not take long to extinguish the fire. Fully ventilated with roof gone.
Breathing apparatus removed, turning over continued
The BA was worn down to the time of whistle (approx 30 minutes wear) and in the absence of the Sub O and supervisory the LFf and Ff removed BA deeming that the fire was out. There was some heat left in the remnants and it was a case of finding the hotspots and using the hose reel to fully extinguish. 2 retained firefighters assisted the WT LFf & Ff in clearing out some debris.
2 Plastic containers identified during turn over phase
The LFf found 2 plastic containers that had been in a ‘kitchen’ cupboard base unit that had melted down to approx 6” high where there was some liquid in them. The LFf made the crew aware who were working in the area and marked it with a metal dust bin lid so that no-one would kick it over.
This information relating to the plastic containers was passed to the IC, who confirmed action not to disturb it believing it was cool at this stage.
It was later found that one of these contained liquid organic phosphate (sheep dip) and one containing MCPA (a broad leaf weed killer)

15. Photos show the 2 plastic containers that were recovered from the rubbish already dug out by the famer.

16. Significant Points
Supervisory Officer leaves incident with Thermal Image Camera
Incident closes, make up, return to station, off duty at approx 1830hrs
Informed of death on Saturday afternoon
Supervisory Officer leaves incident with Thermal Image Camera
After the stop message, a call came in requesting a thermal image camera for another incident. The supervisory officer (who had not put on his fire kit at any point) left the incident with the TIC from the appliance.
Incident closes, make up, return to station, off duty at approx 1830hrs
Informed of death on Saturday afternoon
The duty watch that attended the incident were off duty on Saturday, but were contacted by colleagues in the afternoon with the tragic news that LFf Mike ‘Sonny’ Liston had died on the rugby pitch 10 minutes into the game.
Sonny was a very good and respected rugby player, but on this day turned up to the rugby club not feeling 100% and did not travel away with the first team. The 3rd team were playing at home and were short and he was talked into playing for them. Ten minutes into the game, he made a good run travelling most of the length of the pitch to score a try. On jogging back to the half way line, he collapsed grasping his chest. CPR was immediately carried out by another FF playing and an ambulance called.

17. Significant Points Occupational Health & GP Involvement
Brigade & Coroner Investigation commences
Occupational Health & GP Involvement
As a precaution, the WT FF was booked sick for a week and asked to seek his GP involvement. ECG was undertaken but proved no issues.
Subsequently, 1 of the retained FF’s developed chest conditions and was admitted to hospital for a week and later discharged.
Brigade & Coroner Investigation commences
During the shift the crew had also attended a number of other fires (bins, skips & car) and all of these were considered.
Post Mortem & Toxicology report
In laboratory a number of tests were undertaken and it took a couple of days to find that at a certain temperature the organic phosphate produced phosgene
Phosgene (Mustard Gas)

18. Photo shows the recovery of the containers by a FRS crews wearing GTS.

19. Significant Points Post Mortem & Toxicology report
Phosgene (Mustard Gas)
Occupational Health & GP Involvement
As a precaution, the WT FF was booked sick for a week and asked to seek his GP involvement. ECG was undertaken but proved no issues.
Subsequently, 1 of the retained FF’s developed chest conditions and was admitted to hospital for a week and later discharged.
Brigade & Coroner Investigation commences
During the shift the crew had also attended a number of other fires (bins, skips & car) and all of these were considered.
Post Mortem & Toxicology report
In laboratory a number of tests were undertaken and it took a couple of days to find that at a certain temperature the organic phosphate produced phosgene
Phosgene (Mustard Gas)

20. MCPA Meta ChloroPhenyl Acetic acid MCPA is used as an herbicide
Kills broad leaf plants not grasses so used on pasture
Still used extensively in the UK

21. Heating & Cooling of MCPA
Phosgene
Temperature
A chemist will confirm, but the above graph (not an exact science) tries to show were the phosgene was recorded in the cooling phase (at the time of turning over and damping down).

22. CHEMDATA PUBLIC NOTE !!!!

23. Significant Points Fire Brigade’s acceptance of responsibility
HSE prosecuted Farmer
The FRS made an out of court settlement to the family and admitted responsibility.
The HSE prosecuted the farmer for inadequate storage and signage arrangements.

24. National Procedure Changes
TB1/97 “Command & Control”
Incident Command System “Formal handover of Incidents”
Through the inquest, there was some in depth questioning regarding whose decision was it that there no longer any respiratory risk and could remove BA.
At the time we were operating under TB1/89, subsequently in TB1/97 there is clear guidance that “BA will only be removed at the insrtcution of the IC”.
There was also in depth questioning and debate as to who was in charge of the fire as a supervisory officer attended, but never dressed in fire kit etc. The Incident Command manual subsequently addressed the requirement for a ‘clearly identifiable IC’ and handover.