ESC update: Rosepark Care Home inquiry
The findings of an inquiry into an electrical fire at the Rosepark Care Home in Lanarkshire that claimed the lives of 14 elderly residents in January 2004 were published in April. The fire also left four people injured. The fatal accident inquiry, the longest in Scottish legal history, was told
that in terms of numbers of lives lost, it was the most significant fire in the UK since the King’s Cross fire in 1987. The main purpose of the inquiry was to ensure lessons were learned for the future. The inquiry found that numerous factors had contributed to the
deaths, but deficiencies in the construction, alteration and maintenance of the electrical installation were key amongst them. The inquiry determined that the fire resulting in the deaths was caused by an earth fault occurring as the result of abrasion at the point where a cable (supplying two commercial washing machines) passed through a knockout at the back of a metal-enclosed electrical distribution board located in a cupboard in a corridor. Amongst other things, the inquiry determined that the reasonable precautions whereby the accident and the deaths might have been avoided included: n The fitting of a grommet or other protection against abrasion or damage over time where the cable passed though the enclosure of the distribution board when the installation was constructed, and in any event when the cable that suffered the fault was subsequently installed. n The cable being installed in such a manner that the cable sheath was protecting the insulated conductors as they passed through the knockout. n The distribution board being inspected and tested in accordance with BS 7671 at least on the following occasions: On completion of the electrical installation at Rosepark Care Home in 1992; When the installation was modified in 1998 to add the cable to supply a new washing machine arrangement; and Not later than the fifth and tenth anniversaries of the completion of the electrical installation.
n The storage of combustible materials in the cupboard being minimised. n The doors to the cupboard being fire-resisting. n Having an effective system of electrical maintenance. Tests arranged by the HSE at the Health and Safety Laboratory
indicated that thermal movement of a cable, such as would have been caused by the cyclic loads of the commercial washing machines at the care home, can be sufficient in some circumstances to abrade or damage the insulation if it is in contact with a sharp surface, such as an unprotected knockout in a distribution board. Over an extended period of time, the sharp edge can migrate into the insulation, eventually causing insulation failure. The tests illustrated that, although the cable was nominally
overloaded, the diversity factor associated with the operation of the washing machines meant that it would not have reached temperatures capable of causing thermal damage to the insulation. The tests also illustrated the potential for incendive sparks to be expelled from distribution boards under fault conditions, particularly through cable holes and through unused circuit-breaker ways if blanking plates are not in place.
The ESC is working with the Fire and Rescue Service and the electrical supply industry to introduce a new label to warn householders and others not to store combustible materials near electrical equipment, to help avoid such fires.
For more information
Tel: +44 (0) 20 3166 5002
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