Santosh Muthiah
PFD Report
All Responded
Ref: 2014-0476
All 5 responses received
· Deadline: 31 Dec 2014
Sent To
Response Status
Responses
5 of 12
56-Day Deadline
31 Dec 2014
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
Identification of cause of fires heard evidence from various witnesses, including the LFB but also from Beko and formerly of Intertek; that there are often problems in identifying; not just the specific cause of an appliance fire, but even the manufacturer; model and serial number of the appliance in question due to the severity of the fire damage. This has a knock on effect on Fire & Rescue Services' ("FRSs"), Trading Standards' ("TS") and manufacturers' ability to accurately identify a pattern or trend within fires from appliances which may evidence a specific manufacturing or component problem
3. This creates a risk that the nature extent of a potential problem with a particular manufacturer or particular appliance is not fully known and therefore underestimated with the consequence that the risk to the lives of consumers may also be will and
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) underestimated_ 4_ LFB witnesses gave evidence that if manufacturers were to mark their appliances with the model and serial number of their products in such a way that the marking will survive a fire, even if it were severe, this would enable any appliance believed to have caused the fire t0 be properly identified s0 that accurate information can be provided to the manufacturer and TS. accurate information would assist manufacturers when carrying risk assessments and will serve to more accurately identify the nature ad extent of any potential problem ad its consequent risk to the lives of consumers and to TS in order that they can consider whether action should be taken: 5, address these concerns in this report to: Association of Manufacturers of Domestic Appliances (AMDEA)L Rapier House, 40-46 Lambs Conduit Street; London, WCIN 3NW British Standard's Institute , Chairman of CPL/ 61 Committee, 389 Chiswick High Road, W4 4AL, Communication of Information
6. heard evidence the LFB witnesses as to the LFB's practice at the time of Mr Muthiah's death and the present practice in relation to the communication of information gathered by their Fire Investigation Team ("FIT") concerning the cause of appliance fires. 7 , The LFB practice is to communicate information on an appliance fire to both the manufacturer of the appliance ad to TS Where they have been able to identify the manufacturer of the appliance and where the fire investigation has concluded that the cause of the fire was that appliance. In other words, every time that an LFB fire investigator determines that a fire has originated in particular appliance the manufacturer and TS are told; This is not the case routinely elsewhere in the country: There may be variety of More out from
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) reasons for this, including (he difficulty in identifying the appliances due to fire damage, and the more limited resources ad expertise in the investigation of the causes of fires that other FRSs have in contrast to the fortunate position of the LFB. Whatever the reasons there is a risk in existence where such information that is gathered by FRS's in relation to fires involving domestic electrical appliances (where the appliance can be identified) is not routinely passed to the appropriate TS Home or Primary Authority or indeed to the manufacturer: TS is taking decisions on whether to take ay action in relation to a particular manufacturer or particular appliance on less than all the available information: If were provided with more accurate information about the incidences of appliance fires they would be in a better position to take action where necessary:
10. address these concerns in my report to: The Trading Standards Institute , Sylvan Court; Sylvan Way; Southfields Business Park, Basildon, Essex, SS15 6TH; b; Chief Fire Officers Association 9-11 Pebble Close, Amington; Tamworth, Staffordshire, B77 4RD;
11. At present the Department for Communities ad Local Government ("DCLG") does not necessarily pass the data it collects from FRSs, relating to appliance fires (where the make and model are recorded) to TS_
12. Again; there is a risk created where TS is taking decisions on whether to take any action in relation to a particular manufacturer or a particular appliance on less than all the available information; If were provided with more accurate information about the incidences of 'appliance fires they would be in a better position to take action where necessary_ 13, address these concerns in my report to: Deputy Director; National Resilience and Fire Programmes, they they -
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) Department for Communities and Local Government;, 31E1, Third Floor Eland House, Bressenden Place, London, SWIE SDU. 14, heard evidence that companies and organisations which investigate such as insurance companies, legal firms, private fire investigators etc do not, generally, notify TS when the outcome of an investigation is that the cause of a fire is believed to have been the result of a product failure. 15, There is a risk created where TS is taking decisions o whether to take any action in relation to particular manufacturer or particular appliance on less than all the available information: If were provided with more accurate information about the incidences of appliance fires be in a better position to take action where necessary:
16. address my concerns in this report to: Association of British Insurers; 51 Gresham Street; London, ECZV 7HQ; UK-AFI President; Mr J Galvin, Bushey Bartrams, Shenley Brook End; Milton Keynes, MKS 7HE; Mr N, Gibbins, Company Secretary, The Institution of Fire Engineers, IFE House; 64-86 Cygnet Court, Timothys Bridge Road, Stratford-upon-Avon; CV37 9NW; Ann Priston; President;, The Chartered Society of Forensic Scientists, Clarke House; 18A Mount Parade, Harrogate, North Yorkshire, HG1 1BX 17 . Major retailers also do not notify TS when receive reports of failures, including fires, in products reported to them by customers
18. Again, there is a risk created where TS is taking decisions o whether to take ay action in relation to a particular manufacturer or a particular appliance on less than all the available information: If were provided with more' accurate information about the incidences of appliance fires they would be in a better position to take actior where necessary fires, they would they they they
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield)
19. address this concern in my report to: Mr
3. This creates a risk that the nature extent of a potential problem with a particular manufacturer or particular appliance is not fully known and therefore underestimated with the consequence that the risk to the lives of consumers may also be will and
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) underestimated_ 4_ LFB witnesses gave evidence that if manufacturers were to mark their appliances with the model and serial number of their products in such a way that the marking will survive a fire, even if it were severe, this would enable any appliance believed to have caused the fire t0 be properly identified s0 that accurate information can be provided to the manufacturer and TS. accurate information would assist manufacturers when carrying risk assessments and will serve to more accurately identify the nature ad extent of any potential problem ad its consequent risk to the lives of consumers and to TS in order that they can consider whether action should be taken: 5, address these concerns in this report to: Association of Manufacturers of Domestic Appliances (AMDEA)L Rapier House, 40-46 Lambs Conduit Street; London, WCIN 3NW British Standard's Institute , Chairman of CPL/ 61 Committee, 389 Chiswick High Road, W4 4AL, Communication of Information
6. heard evidence the LFB witnesses as to the LFB's practice at the time of Mr Muthiah's death and the present practice in relation to the communication of information gathered by their Fire Investigation Team ("FIT") concerning the cause of appliance fires. 7 , The LFB practice is to communicate information on an appliance fire to both the manufacturer of the appliance ad to TS Where they have been able to identify the manufacturer of the appliance and where the fire investigation has concluded that the cause of the fire was that appliance. In other words, every time that an LFB fire investigator determines that a fire has originated in particular appliance the manufacturer and TS are told; This is not the case routinely elsewhere in the country: There may be variety of More out from
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) reasons for this, including (he difficulty in identifying the appliances due to fire damage, and the more limited resources ad expertise in the investigation of the causes of fires that other FRSs have in contrast to the fortunate position of the LFB. Whatever the reasons there is a risk in existence where such information that is gathered by FRS's in relation to fires involving domestic electrical appliances (where the appliance can be identified) is not routinely passed to the appropriate TS Home or Primary Authority or indeed to the manufacturer: TS is taking decisions on whether to take ay action in relation to a particular manufacturer or particular appliance on less than all the available information: If were provided with more accurate information about the incidences of appliance fires they would be in a better position to take action where necessary:
10. address these concerns in my report to: The Trading Standards Institute , Sylvan Court; Sylvan Way; Southfields Business Park, Basildon, Essex, SS15 6TH; b; Chief Fire Officers Association 9-11 Pebble Close, Amington; Tamworth, Staffordshire, B77 4RD;
11. At present the Department for Communities ad Local Government ("DCLG") does not necessarily pass the data it collects from FRSs, relating to appliance fires (where the make and model are recorded) to TS_
12. Again; there is a risk created where TS is taking decisions on whether to take any action in relation to a particular manufacturer or a particular appliance on less than all the available information; If were provided with more accurate information about the incidences of 'appliance fires they would be in a better position to take action where necessary_ 13, address these concerns in my report to: Deputy Director; National Resilience and Fire Programmes, they they -
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) Department for Communities and Local Government;, 31E1, Third Floor Eland House, Bressenden Place, London, SWIE SDU. 14, heard evidence that companies and organisations which investigate such as insurance companies, legal firms, private fire investigators etc do not, generally, notify TS when the outcome of an investigation is that the cause of a fire is believed to have been the result of a product failure. 15, There is a risk created where TS is taking decisions o whether to take any action in relation to particular manufacturer or particular appliance on less than all the available information: If were provided with more accurate information about the incidences of appliance fires be in a better position to take action where necessary:
16. address my concerns in this report to: Association of British Insurers; 51 Gresham Street; London, ECZV 7HQ; UK-AFI President; Mr J Galvin, Bushey Bartrams, Shenley Brook End; Milton Keynes, MKS 7HE; Mr N, Gibbins, Company Secretary, The Institution of Fire Engineers, IFE House; 64-86 Cygnet Court, Timothys Bridge Road, Stratford-upon-Avon; CV37 9NW; Ann Priston; President;, The Chartered Society of Forensic Scientists, Clarke House; 18A Mount Parade, Harrogate, North Yorkshire, HG1 1BX 17 . Major retailers also do not notify TS when receive reports of failures, including fires, in products reported to them by customers
18. Again, there is a risk created where TS is taking decisions o whether to take ay action in relation to a particular manufacturer or a particular appliance on less than all the available information: If were provided with more' accurate information about the incidences of appliance fires they would be in a better position to take actior where necessary fires, they would they they they
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield)
19. address this concern in my report to: Mr
Responses
Response received
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Dear Mr Walker Response from the Association of Manufacturers of Domestic Appliances Further to your report dated 5 November 2014, AMDEA wishes to reply to the points 2 to 4 of your report as follows_ We accept that there are difficulties in identifying products and components that fail but in most cases the fire officers with specialist knowledge (such as are found in the London Fire Brigade) with assistance company specialists can overcome the difficulties preserited when product is burnt out and only a carcass remains: Over the past few years industry and the fire service have held regular meetings at AMDEA and we ensure that the services are supplied with contact details for all our members The idea of marking the product in some way that will survive a fire has been discussed in this group. It is accepted that such marking would have to be a separate marking in the steelwork at the base of the product whereas the plate needs to be at a level easily accessible to the consumer. This marking would only have value in event of a catastrophic fire which is an extremely rare event: The location would have to be known to the fire services and with the manufacturing products sourced throughout the world this would need world-wide agreement: Also the metal structure of these appliances can be used across range of appliances and range of brands, some of which are retailers own brands and some of which are the brands of other manufacturers: It would be very difficult to set up a standard for this with international acceptance since it would not be considered to be a safety matter by IEC. LFB have argued that manufacturers who provided such marking would also avoid the situation of their products being misidentified, as has happened in the past. This is now understood and discussions are continuing both in UK and European industry fora. AMDEA Rapier House 40-46 Lambs Conduit Street London WCIN 3NW +.+44 (0120 7405 0666 444 7405 6609 info@amdea org.uk wwwamdea orguk Chairman: Maurizio Pettorino Chief Executive: Douglas Herbison A company limited by guarantee Registered in England No. 1465823 from fire rating being (0120
With reference_to_the construction of refrigeration appliances (36 t0 40): the Technical Manager on Refrigeration within AMDEA together with industry safety specialists prepared a basic proposal for change to the international standard IEC 60335-2-24 to cover these points. This work arose because of a previous incident This proposal was placed before the BSI committee CPL61 and, was accepted as a UK proposal for change at international level in 2014. in his role as Chairman of BSI committee CPL/61 and UK delegate at recent International Electrotechnical Commission (IEC) meeting in Tokyo, Japan, presented the UK proposal which was subsequently accepted by the meeting_ Full details of this standards activity contained in the correspondence to yourself from the BSI have included an extract from] (report for completeness With regard to point 39 the insulation material used in refrigeration appliances: whilst this is highly flammable it has been successfully used for at least 30 years and is currently the only way to meet the performance requirements of the Ecodesign Regulation as part of the industry's commitment to reduce greenhouse gas emissions. We believe that their continued use, with slight changes in the materials used to contain them, will be satisfactory. It is vital that any change to refrigeration products is accepted at international level since there is no major manufacturing of household refrigeration products in the UK We believe that we have taken note of the recommendations in the Coroner's report and will continue our dialogue with industry colleagues worldwide to address these concerns
With reference_to_the construction of refrigeration appliances (36 t0 40): the Technical Manager on Refrigeration within AMDEA together with industry safety specialists prepared a basic proposal for change to the international standard IEC 60335-2-24 to cover these points. This work arose because of a previous incident This proposal was placed before the BSI committee CPL61 and, was accepted as a UK proposal for change at international level in 2014. in his role as Chairman of BSI committee CPL/61 and UK delegate at recent International Electrotechnical Commission (IEC) meeting in Tokyo, Japan, presented the UK proposal which was subsequently accepted by the meeting_ Full details of this standards activity contained in the correspondence to yourself from the BSI have included an extract from] (report for completeness With regard to point 39 the insulation material used in refrigeration appliances: whilst this is highly flammable it has been successfully used for at least 30 years and is currently the only way to meet the performance requirements of the Ecodesign Regulation as part of the industry's commitment to reduce greenhouse gas emissions. We believe that their continued use, with slight changes in the materials used to contain them, will be satisfactory. It is vital that any change to refrigeration products is accepted at international level since there is no major manufacturing of household refrigeration products in the UK We believe that we have taken note of the recommendations in the Coroner's report and will continue our dialogue with industry colleagues worldwide to address these concerns
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Dear Mr Walker Response from British Standards Institution on behalf of BSI Committees CPL/61 and PEL/33 Further to your report dated 5 November 2014, BSI is now in a position to advise that the Committees CPL/61 and PEL/33 have reviewed points 36 to 48 therein in relation to the following British Standards: BS EN 60252-1: AC motor capacitors Part 1: General Performance, testing and rating Safety requirements Guidance for installation and operation; BS EN 60335-1: Household and similar electrical appliances; Safety Part 1: General requirements; BS EN 60335-2-24: Household and similar electrical appliances: Safety. Particular requirements for refrigerating appliances, ice-cream appliances and ice makers As you will be aware these are British Standards which are based on European harmonized standards which are in turn based upon International IEC standards: change we wish to make to the British Standard must be submitted by way of proposal to the International Committee and/or the European Committee and is then subject to formal voting procedures. The response from BSI to the points in the report which were addressed to CPL/61 and PEL/33 is as follows: Construction of_refrigeration appliances (36_to 402: Item 36) The high fuel load from the polyurethane insulation material is necessary to achieve the high level of performance required by the Eco-design Directive: BSI Group T:+44 20 845 086 9001 British Standards Limited 389 Chiswick High Road F: +44 20 8996 7400 Registered in England no: 07864997 London; W4 4AL csenvices@bsigroupcom Registered address: 389 Chiswick High Road INVESTORS IN PEOPLE United Kingdom bsigroup.com London; W4 4AL, United Kingdom Any
bsi making excellence a habit" (37) Regarding the matter of protecting foam insulation from the risk of ignition, the UK has in a proposal on this to the International committee IEC SC 61C and in November 2014 this was agreed to be progressed to a Formal Vote: The proposal requires a flame retardant covering to be over foam insulation: We believe that if this proposal is accepted internationally and in the EN then item 37 will be resolved. Relevant text from the UK delegate's report from this meeting is attached to this letter. (39) See response to (36) above regarding the first two sentences: The last two sentences are addressed by the UK proposal which was agreed to progress at the IEC SC 61C meeting in November which improves the testing to ensure the fire resistance of the outer materials of the fridgelfreezer. Relevant text from the UK delegate's report from this meeting is attached to this letter . Capacitors (41 to 48) It is important to note that the capacitors standard was amended in 2013 and is now designated as BS EN 60252-1:2011+41.2013 This includes new features' associated with segmented metallised dielectrics, Clause 3.22.4 and a revision of the destruction test; Clause 5.16. In this amendment; a new identification was introduced replacing the old safety classes PO, P1 and PZ. This was done to make sure that any capacitors could be clearly identified as meeting the new classes SO, S1, S2 and 53. Class SO (formerly PO) does not have any specific safety protection: Class S1 (formerly P1) is protected against fire and shock hazard but may fail in the open-circuit or short-circuit mode; Class S2 (formerly P2) is protected against fire and shock hazard but must fail in the open-circuit mode only. Class S3 is a new category covering segmented film construction and has protection against fire and shock hazard: Capacitors in this class are required to fail with low residual capacitance ( <1% CN): The recommendation of PEL/33 is that: 1 BS EN 60335-1.2012 should be amended to refer to BS_EN_60252-1-2011 +Al-2013 which has the new safety classes SO, S1, S2 and S3;
2. IECITC 61/SC 61C has the option of specifying the highest level of safety protection for applications such as refrigeration appliances: In the new amendment; this is referred to as S2 and 53 CPL/61 can advise that as a result of the UK raising the general fire issue both of these recommendations are currently under consideration in the international committee IEC TC 61/SC 61C. We trust that the above demonstrates that where possible BSI is taking on board the recommendations contained in the Coroner's report but we have to advise that we cannot guarantee that our position will prevail at international level. Additionally, it is important to be aware that the whole process of changing the standard and manufacturers changing their designs will take some time: Finally, changing the standard will not eradicate the problem which might exist with products already in use.
bsi making excellence a habit" (37) Regarding the matter of protecting foam insulation from the risk of ignition, the UK has in a proposal on this to the International committee IEC SC 61C and in November 2014 this was agreed to be progressed to a Formal Vote: The proposal requires a flame retardant covering to be over foam insulation: We believe that if this proposal is accepted internationally and in the EN then item 37 will be resolved. Relevant text from the UK delegate's report from this meeting is attached to this letter. (39) See response to (36) above regarding the first two sentences: The last two sentences are addressed by the UK proposal which was agreed to progress at the IEC SC 61C meeting in November which improves the testing to ensure the fire resistance of the outer materials of the fridgelfreezer. Relevant text from the UK delegate's report from this meeting is attached to this letter . Capacitors (41 to 48) It is important to note that the capacitors standard was amended in 2013 and is now designated as BS EN 60252-1:2011+41.2013 This includes new features' associated with segmented metallised dielectrics, Clause 3.22.4 and a revision of the destruction test; Clause 5.16. In this amendment; a new identification was introduced replacing the old safety classes PO, P1 and PZ. This was done to make sure that any capacitors could be clearly identified as meeting the new classes SO, S1, S2 and 53. Class SO (formerly PO) does not have any specific safety protection: Class S1 (formerly P1) is protected against fire and shock hazard but may fail in the open-circuit or short-circuit mode; Class S2 (formerly P2) is protected against fire and shock hazard but must fail in the open-circuit mode only. Class S3 is a new category covering segmented film construction and has protection against fire and shock hazard: Capacitors in this class are required to fail with low residual capacitance ( <1% CN): The recommendation of PEL/33 is that: 1 BS EN 60335-1.2012 should be amended to refer to BS_EN_60252-1-2011 +Al-2013 which has the new safety classes SO, S1, S2 and S3;
2. IECITC 61/SC 61C has the option of specifying the highest level of safety protection for applications such as refrigeration appliances: In the new amendment; this is referred to as S2 and 53 CPL/61 can advise that as a result of the UK raising the general fire issue both of these recommendations are currently under consideration in the international committee IEC TC 61/SC 61C. We trust that the above demonstrates that where possible BSI is taking on board the recommendations contained in the Coroner's report but we have to advise that we cannot guarantee that our position will prevail at international level. Additionally, it is important to be aware that the whole process of changing the standard and manufacturers changing their designs will take some time: Finally, changing the standard will not eradicate the problem which might exist with products already in use.
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Dear Sir; I have been passed a copy of your report dated 5 November 2014 questions and seeking response from the Chartered Society of Forensic Sciences The objects of the Society are to advance the study, application and standing of forensic science and to facilitate cO-operation among persons interested in forensic science throughout the world. It is also the professional body for forensic science practitioners. Forensic Scientists outside academia are usually employed contracted by a third party for their services by the police or other emergency services, including the fire service; solicitors; private businesses Or individuals for criminal, civil and other investigative work O advice. Their reports are therefore delivered direct to whoever has engaged them and, depending on the circumstances and purpose, are not always available for wider circulation and may be sensitive or confidential_ A forensic scientist will not be called to assist at the scene or even with any aspect of the majority of fire investigations_ are rarely involved in any but the most serious fires and Or unexplained or suspicious deaths. Reasonably straightforward cases where the cause of the fire is readily assessed will usually be investigated by the fire service and or 'police without an external forensic scientist' s involvement are not therefore, in my opinion; placed to be able to report; or be required to report; information such as a specific appliance or apparatus that may have been the cause ofa fire. The fire service, understand, have a to investigate fire and the police will be involved in fatalities. Scientific evidence may be available to assist them to reach a conclusion or suggest lines of enquiry but not necessarily involving input from a forensic scientist The Chartered Society of Forensic Sciences Clarke House 18a Mount Parade Harrogate HG1 1BX Tel: 00 44 (011423 506068 or 00 44 (011423 566973 Fax: 00 44 (011423 566391 Email: info@csofs org Website: WWW charteredsocietyofforensicsciences org Registered Charity No.1156052 Company No.RCO0869 raising They best They duty every
Supporting forensic practice worldwide The Chartered Society of Forensic Sciences Patron: The Hon. Mr Justice Sweeney In order to provide consistent and accurate data to a central monitoring body such as Trading Standards I believe responsibility should rest with a single agency that will always be involved and already has a duty to investigate, i.e. The Fire and Rescue Services Local Authority. Please do not hesitate to contact me should you need further information or if I can assist in any way.
Supporting forensic practice worldwide The Chartered Society of Forensic Sciences Patron: The Hon. Mr Justice Sweeney In order to provide consistent and accurate data to a central monitoring body such as Trading Standards I believe responsibility should rest with a single agency that will always be involved and already has a duty to investigate, i.e. The Fire and Rescue Services Local Authority. Please do not hesitate to contact me should you need further information or if I can assist in any way.
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Dear Mr Walker REGULAJION 28 REPORI JIQ PREVENT FUIURE DEATHS SANIOSH BENJAMIN MUTHIAH am writing in response to your letter of Sth November 2014, under Regulation 28 of the Coroners (Investigations) Regulations 2013,relating to the inquest into the tragic death of Mr Santosh Benjamin Muthiah: Before responding to your earlier correspondence, would first like to express and place on record my deepest condolences to Mr Muthiah'$ family. Firstly, by way of an introduction | am the Deputy Chief Fire Officer of Humberside Fire and Rescue Service and_ also the Chief Fire Officers Association (CFOA) Lead Officer for Fire Investigation. In this capacity also chair CFOA '$ Fire Investigation Strategic Steering Group (FISSG) _ CFOA is a charity whose purpose is to promote and increase efficiency amongst the UK'$ Fire and Rescue Services (FRS) for the benefit of the public and all communities across the Country. It is important to note that my CFOA role does not authorise me to mandate any FRS to undertake a particular course of action. Whilst this is the case, can produce guidance and recommend to the CFOA Board that this be issued to FRS in order to support Association'$ purpose Page of 3 Chief Fire Officers Association 9-1 1 Pebble Close Amington Tamworth Staffordshire B77 4RD Registered in England &8 Limited Company N 02677186 Telephone +44 (0J1827 302300 Fax +44 (0J1827 302399 WWW cfoa org;Uk Aegistured in England 0s Charily Na 1074071 VAT Registralion No: 902 1954 46 the
As your letter relates to the sharing of information following investigations into the origin and cause of a it is also important to note that whilst the Fire and Rescue Services Act 2004,in particular Section 45 of that Act, does give the FRS powers to obtain information and investigate fires, it does not place a specific duty on them to do so. Therefore, whilst all UK FRS currently investigate fires to an extent, it cannot be guaranteed in the absence of statutory duty, the level that FRS will continue to investigate [fires] in the future. Despite that fact, would assert that Fire Investigation remains an important aspect of FRS work and, there is no doubt that the findings from various investigations have helped secure and safeguard both communities and firefighters alike This has been achieved through the identification of trends and emergent issues and, sharing information with partners and stakeholders In this regard | acknowledge that there would be benefits in Trading Standards (TS) and manufacturers being provided with more of the information that was available relating to appliance fires: In this respect, can report that there has been work on going since early 2014, initiated by the aforementioned CFOA FISSG, to improve the ability for the FRS to share information and intelligence with TS, Following meeting in June 2014, hosted by the Government's Business Innovations and Skills Department (BIS) , there was agreement by all stakeholders, including CFOA, the Department of Local Government (DCLG) and the Association of Trading Standards Officers (ACTSO) that information sharing Ibetween the FRS and TS was important and, as a result, BIS undertook to carry out exploratory research on how that might be achieved most effectively through web based means: CFOA continue to engage proactively on this project and are currently awaiting an update from BIS_ Ialso note that in your letter YOU address & number of concerns tol DCLG Deputy Director National Resilience and Fire Programme: It appears that those concerns are around a similar area of data sharing: On this matter, would comment as follows: All UK FRSs provide information as to the cause of and the extent of damage caused by fire, to DCLG via their Incident Recording System (IRS). This is provided for every fire attended by the FRS and is generally gathered by frontline crews at the scene, rather than dedicated Fire Investigators who are mobilised depending on local circumstances but mostly where incidents are likely to be protracted or complicated: In respect to subject matter, these routine reports will include the make and model of the appliance where that information is available. have discussed the overlap between the two areas that we are responding to with and some of her colleagues. Whilst am not in @ position to comment upon the capacity for DCLG to change any processes do believe that there may be opportunities to work to enhance some of the information gathered for IRS. As a result it may be possible to consider the ways that information is currently recorded and accessed thereby providing a more sustainable method to inform both TS and manufacturers of the information that YoU suggest on a regular basis. CFOA are already engaged with a working party developing the replacement IRS system, moreover there is an FISSG member to provide specific inputs on FI related matters. On this matter, my opinion is that if @ system was developed to extract information on those fires where the FRS had reported to DCLG in 8.1 of the IRS as being caused by "fault in equipment or appliance" and the manufacturer and/or model number was known and reported to DCLG in 8.2 of the IRS, then even that limited information may be useful to both TS and manufacturers There are clear benefits in such a system being administered centrally Using existing means rather than relying on the potential discrepancies caused by local inputs associated with a revised individual FRS arrangement: To illustrate this point, would refer to the lack of statutory duty around the investigation of fires and the current variations across the UK in respect to information is gathered and disseminated: Whilst this is the case, the requirement for each FRS to complete the IRS as described above is one which DCLG can continue to demand under Section 26 of the Fire and Rescue Services Act as it places a duty upon and Rescue Authorities to "submit to the Secretary of State any reports and returns required by him_
Chief Fire Olficers Association 9-1 Pebble Closa Amington Ternworth Statiordshire 877 4RD Rcrlstescd in Engam) 33 Lthied Company: No 02677126 Telephone +44 (0)1827 302300 Fax +44 (0Ji827 302399 wvwwctoa crg,uk Regjistered in Englanc] & Chfaiy No 1074371 VAT Rcg ralion No. 002 1954 4 fire , fires the how Fire
Proposals for further action by CFOA CFOA will continue to engage proactively with the work which BIS are progressing regarding information sharing between FRS and TS. As the nominated person for that work will ensure that CFOA provide any support within the timescales required by BIS_ CFOA will continue to engage proactively with DCLG to help develop the future IRS, and the ease by which this type of information can be gathered, accessed and disseminated. The timetable for that work is OUtside of the control of CFOA buf the Association has nominated an officer to be part of the working group and support as required_ CFOA will provide guidance to FRS by April 2015 to help ensure that the information provided on IRS is as accurate and meaningful as is possible to facilitate the ease by which DCLG could provide it to TS and manufacturers if they decided to do s0_ If DCLG determine it is not feasible to provide meaningful information to both TS and manufacturers on a periodic basis then CFOA, in consultation with DCLG, will provide guidance to each UK FRS on methods to be used in order to identify appliances involved in fire and the manner in which this is to be recorded and information shared with other partners; including TS and manufacturers. It must be acknowledged that this cannot be mandated, or indeed monitored by CFOA going forward: Depending on the response from DCLG this will be provided to FRS, even only as an interim measure that they may decide to adopt, by Ist April 2015. Once again please allow me to express my deepest condolences to Mr Muthiah'$ family. CFOA are committed to working with its members and partners in order to reduce the tragic incidences of deaths caused by fire in the UK and would welcome sight of responses from the other organisations that you have written to in order for Us to best understand how to achieve our dims:
As your letter relates to the sharing of information following investigations into the origin and cause of a it is also important to note that whilst the Fire and Rescue Services Act 2004,in particular Section 45 of that Act, does give the FRS powers to obtain information and investigate fires, it does not place a specific duty on them to do so. Therefore, whilst all UK FRS currently investigate fires to an extent, it cannot be guaranteed in the absence of statutory duty, the level that FRS will continue to investigate [fires] in the future. Despite that fact, would assert that Fire Investigation remains an important aspect of FRS work and, there is no doubt that the findings from various investigations have helped secure and safeguard both communities and firefighters alike This has been achieved through the identification of trends and emergent issues and, sharing information with partners and stakeholders In this regard | acknowledge that there would be benefits in Trading Standards (TS) and manufacturers being provided with more of the information that was available relating to appliance fires: In this respect, can report that there has been work on going since early 2014, initiated by the aforementioned CFOA FISSG, to improve the ability for the FRS to share information and intelligence with TS, Following meeting in June 2014, hosted by the Government's Business Innovations and Skills Department (BIS) , there was agreement by all stakeholders, including CFOA, the Department of Local Government (DCLG) and the Association of Trading Standards Officers (ACTSO) that information sharing Ibetween the FRS and TS was important and, as a result, BIS undertook to carry out exploratory research on how that might be achieved most effectively through web based means: CFOA continue to engage proactively on this project and are currently awaiting an update from BIS_ Ialso note that in your letter YOU address & number of concerns tol DCLG Deputy Director National Resilience and Fire Programme: It appears that those concerns are around a similar area of data sharing: On this matter, would comment as follows: All UK FRSs provide information as to the cause of and the extent of damage caused by fire, to DCLG via their Incident Recording System (IRS). This is provided for every fire attended by the FRS and is generally gathered by frontline crews at the scene, rather than dedicated Fire Investigators who are mobilised depending on local circumstances but mostly where incidents are likely to be protracted or complicated: In respect to subject matter, these routine reports will include the make and model of the appliance where that information is available. have discussed the overlap between the two areas that we are responding to with and some of her colleagues. Whilst am not in @ position to comment upon the capacity for DCLG to change any processes do believe that there may be opportunities to work to enhance some of the information gathered for IRS. As a result it may be possible to consider the ways that information is currently recorded and accessed thereby providing a more sustainable method to inform both TS and manufacturers of the information that YoU suggest on a regular basis. CFOA are already engaged with a working party developing the replacement IRS system, moreover there is an FISSG member to provide specific inputs on FI related matters. On this matter, my opinion is that if @ system was developed to extract information on those fires where the FRS had reported to DCLG in 8.1 of the IRS as being caused by "fault in equipment or appliance" and the manufacturer and/or model number was known and reported to DCLG in 8.2 of the IRS, then even that limited information may be useful to both TS and manufacturers There are clear benefits in such a system being administered centrally Using existing means rather than relying on the potential discrepancies caused by local inputs associated with a revised individual FRS arrangement: To illustrate this point, would refer to the lack of statutory duty around the investigation of fires and the current variations across the UK in respect to information is gathered and disseminated: Whilst this is the case, the requirement for each FRS to complete the IRS as described above is one which DCLG can continue to demand under Section 26 of the Fire and Rescue Services Act as it places a duty upon and Rescue Authorities to "submit to the Secretary of State any reports and returns required by him_
Chief Fire Olficers Association 9-1 Pebble Closa Amington Ternworth Statiordshire 877 4RD Rcrlstescd in Engam) 33 Lthied Company: No 02677126 Telephone +44 (0)1827 302300 Fax +44 (0Ji827 302399 wvwwctoa crg,uk Regjistered in Englanc] & Chfaiy No 1074371 VAT Rcg ralion No. 002 1954 4 fire , fires the how Fire
Proposals for further action by CFOA CFOA will continue to engage proactively with the work which BIS are progressing regarding information sharing between FRS and TS. As the nominated person for that work will ensure that CFOA provide any support within the timescales required by BIS_ CFOA will continue to engage proactively with DCLG to help develop the future IRS, and the ease by which this type of information can be gathered, accessed and disseminated. The timetable for that work is OUtside of the control of CFOA buf the Association has nominated an officer to be part of the working group and support as required_ CFOA will provide guidance to FRS by April 2015 to help ensure that the information provided on IRS is as accurate and meaningful as is possible to facilitate the ease by which DCLG could provide it to TS and manufacturers if they decided to do s0_ If DCLG determine it is not feasible to provide meaningful information to both TS and manufacturers on a periodic basis then CFOA, in consultation with DCLG, will provide guidance to each UK FRS on methods to be used in order to identify appliances involved in fire and the manner in which this is to be recorded and information shared with other partners; including TS and manufacturers. It must be acknowledged that this cannot be mandated, or indeed monitored by CFOA going forward: Depending on the response from DCLG this will be provided to FRS, even only as an interim measure that they may decide to adopt, by Ist April 2015. Once again please allow me to express my deepest condolences to Mr Muthiah'$ family. CFOA are committed to working with its members and partners in order to reduce the tragic incidences of deaths caused by fire in the UK and would welcome sight of responses from the other organisations that you have written to in order for Us to best understand how to achieve our dims:
Response received
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Department for Business Victoria Street London Innovation & Skills SWIH OET Mr A Walker T +44 (0) 20 7215 5000 E enquiries@bis gov.uk Senior Coroner North London Coroners Court 29 Wood Street
Barnet ENS 4BE 26 January 2015 AtMrUlllces;, REGULATION 28 REPORT_ SANTOSH BENJAMIN MUTHIAH Thank you for the copy of your Regulation 28 Report to Prevent Future Deaths; which you have addressed to Head of Product Regulation and the Department for Business, Innovation and Skills am replying as this matter falls within my portfolio. The death of Santosh Benjamin Muthiah in November 2010 was a tragic incident and share your interest in preventing a reoccurrence The first two concerns you have addressed to me relate to differences in approach to undertaking risk assessments of products (paragraphs 26-29) , and inconsistencies in the related guidance (paragraphs 31-34). My view on this is that the legislation itself is clear; and that this is underpinned by equally clear guidance (produced by Prosafe, a non-profit making organisation which draws together European Market Surveillance Authorities to spread and develop best practice, with support from the UK): The Government plays a leading role in discussions on risk assessment and corrective action in the EU, and we will continue to promote best practice and draw attention to the Prosafe guidance on this basis. However we are aware that there may be additional guidance in the public domain that is not fully consistent with Prosafe advice_ Whilst it is important to note that risk assessment is an inherently subjective activity, share your concern that any apparent divergence in approach could cause confusion for manufacturers in relation to their obligations As a result; consistency of guidance and sharing of best practice is something that will be considered as part of the independent review of consumer product recalls recently announced by Baroness Neville-Rolfe during a House of Lords debate on the Consumer Rights Bill. The review will incorporate views from a range of Market Surveillance Authorities and other business and non-government stakeholders. The output will be a report to BIS Ministers highlighting the strengths and weaknesses of the current system and making recommendations on how it might be improved. You also raise a series of concerns in paragraphs 52-57 The first of these relates to the creation of a website where all product recalls can be registered and accessed by consumers_ There are already a number of initiatives in this area including AMDEA's 'Register my Appliance' site launched on 15 January, as well as the online list of product recalls maintained Jo Swinson MP Minister for Employment Relations and Consumer Affairs
by the Trading Standards Institute. Nevertheless, the usefulness and feasibility of such a website will be considered as part of the aforementioned independent review: Your second concern in this section relates to white goods carrying key information on a fire- resistant plate or similar. understand that this idea has a number of practical challenges associated with it, but believe that industry are looking into it in some detail and are seeking to make a proposal with the aim of securing global agreement: BIS will continue to support their efforts in this area_ Your third concern covers the "failure to notify" offences under the General Product Safety Regulations 2005 and, in particular; whether the range of penalties is sufficient and whether the time limits for instituting criminal proceedings are too short In my view; the general scheme of offences in the 2005 Regulations operates in a proportionate and effective manner: In relation to penalties, it is important to appreciate that a producer or distributor who commits an offence under regulations 7 or 9 (the "failure to notify" offences) , will very frequently also have committed an offerice under regulations 5 (general safety requirement) or 8 (obiigations of distributors) , to which higher penalties can be applied. In addition, you may be aware that the Ministry of Justice is currently working on commencing section 85(1) of the Legal Aid, Sentencing and Punishment of Offenders Act 2012, which would have the effect of permitting a fine of any amount to be given in respect of the "failure to notify" offences. In relation to time limits , agree that the system must allow sufficient time for effective prosecutions to be brought However; the system must also be proportionate and certain: Therefore, do not propose to address the range of penalties or the time limits applying to the "failure to notify" offences under the 2005 Regulations any further at this time_ Your fourth concern centres on collection and storage of consumers' contact details by retailers As you will appreciate, there are some challenging issues here in relation to data protection, as well as customers' general willingness to give their contact details. This is why BIS's approach focusses on encouraging consumers to register their appliances and helping them understand why this is beneficial, rather than forcing them to do sO. This is exactly what AMDEA's Register my Appliance site is designed to and we will continue to support that initiative_ Finally, you raise concerns about the absence of a Code of Practice on product recalls: believe that much of the content that one would expect to see in a Code of Practice is covered by the Prosafe guidance mentioned above. In addition, it is difficult to set out firm criteria for product recalls, since each one must be tailored according to a huge number of factors including the nature and age of the product; the nature of the risk; the number of products on the market and the consumers affected_ Once again, however; the potential for a Code of Practice will be considered as part of the independent review. In addition to the points above, would like to highlight that the independent review of product recalls also consider a number of the other concerns you have raised elsewhere in your report: understand that views will be sought coroners as part of the evidence gathering that underpins the review: would of course be happy to send you details of the review's findings when it concludes later in the year JO SWINSON MP RECEIEZ Minister for Employment Relations and Consumer Affairs 2 9 JAN 2063 do, will from
Barnet ENS 4BE 26 January 2015 AtMrUlllces;, REGULATION 28 REPORT_ SANTOSH BENJAMIN MUTHIAH Thank you for the copy of your Regulation 28 Report to Prevent Future Deaths; which you have addressed to Head of Product Regulation and the Department for Business, Innovation and Skills am replying as this matter falls within my portfolio. The death of Santosh Benjamin Muthiah in November 2010 was a tragic incident and share your interest in preventing a reoccurrence The first two concerns you have addressed to me relate to differences in approach to undertaking risk assessments of products (paragraphs 26-29) , and inconsistencies in the related guidance (paragraphs 31-34). My view on this is that the legislation itself is clear; and that this is underpinned by equally clear guidance (produced by Prosafe, a non-profit making organisation which draws together European Market Surveillance Authorities to spread and develop best practice, with support from the UK): The Government plays a leading role in discussions on risk assessment and corrective action in the EU, and we will continue to promote best practice and draw attention to the Prosafe guidance on this basis. However we are aware that there may be additional guidance in the public domain that is not fully consistent with Prosafe advice_ Whilst it is important to note that risk assessment is an inherently subjective activity, share your concern that any apparent divergence in approach could cause confusion for manufacturers in relation to their obligations As a result; consistency of guidance and sharing of best practice is something that will be considered as part of the independent review of consumer product recalls recently announced by Baroness Neville-Rolfe during a House of Lords debate on the Consumer Rights Bill. The review will incorporate views from a range of Market Surveillance Authorities and other business and non-government stakeholders. The output will be a report to BIS Ministers highlighting the strengths and weaknesses of the current system and making recommendations on how it might be improved. You also raise a series of concerns in paragraphs 52-57 The first of these relates to the creation of a website where all product recalls can be registered and accessed by consumers_ There are already a number of initiatives in this area including AMDEA's 'Register my Appliance' site launched on 15 January, as well as the online list of product recalls maintained Jo Swinson MP Minister for Employment Relations and Consumer Affairs
by the Trading Standards Institute. Nevertheless, the usefulness and feasibility of such a website will be considered as part of the aforementioned independent review: Your second concern in this section relates to white goods carrying key information on a fire- resistant plate or similar. understand that this idea has a number of practical challenges associated with it, but believe that industry are looking into it in some detail and are seeking to make a proposal with the aim of securing global agreement: BIS will continue to support their efforts in this area_ Your third concern covers the "failure to notify" offences under the General Product Safety Regulations 2005 and, in particular; whether the range of penalties is sufficient and whether the time limits for instituting criminal proceedings are too short In my view; the general scheme of offences in the 2005 Regulations operates in a proportionate and effective manner: In relation to penalties, it is important to appreciate that a producer or distributor who commits an offence under regulations 7 or 9 (the "failure to notify" offences) , will very frequently also have committed an offerice under regulations 5 (general safety requirement) or 8 (obiigations of distributors) , to which higher penalties can be applied. In addition, you may be aware that the Ministry of Justice is currently working on commencing section 85(1) of the Legal Aid, Sentencing and Punishment of Offenders Act 2012, which would have the effect of permitting a fine of any amount to be given in respect of the "failure to notify" offences. In relation to time limits , agree that the system must allow sufficient time for effective prosecutions to be brought However; the system must also be proportionate and certain: Therefore, do not propose to address the range of penalties or the time limits applying to the "failure to notify" offences under the 2005 Regulations any further at this time_ Your fourth concern centres on collection and storage of consumers' contact details by retailers As you will appreciate, there are some challenging issues here in relation to data protection, as well as customers' general willingness to give their contact details. This is why BIS's approach focusses on encouraging consumers to register their appliances and helping them understand why this is beneficial, rather than forcing them to do sO. This is exactly what AMDEA's Register my Appliance site is designed to and we will continue to support that initiative_ Finally, you raise concerns about the absence of a Code of Practice on product recalls: believe that much of the content that one would expect to see in a Code of Practice is covered by the Prosafe guidance mentioned above. In addition, it is difficult to set out firm criteria for product recalls, since each one must be tailored according to a huge number of factors including the nature and age of the product; the nature of the risk; the number of products on the market and the consumers affected_ Once again, however; the potential for a Code of Practice will be considered as part of the independent review. In addition to the points above, would like to highlight that the independent review of product recalls also consider a number of the other concerns you have raised elsewhere in your report: understand that views will be sought coroners as part of the evidence gathering that underpins the review: would of course be happy to send you details of the review's findings when it concludes later in the year JO SWINSON MP RECEIEZ Minister for Employment Relations and Consumer Affairs 2 9 JAN 2063 do, will from
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action,
Report Sections
Investigation and Inquest
On the day of November 2010_ opened an investigation _into_the death of_Santosh and and 23rd
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) Benjamin Muthiah 36 years old. The inquest concluded on the 26" September 2014 The conclusion of the inquest was "Narraitive" the medical case of death was Ia Cerebral Anoxia and under paragraph b Inhalation of Fire Fumes
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) Benjamin Muthiah 36 years old. The inquest concluded on the 26" September 2014 The conclusion of the inquest was "Narraitive" the medical case of death was Ia Cerebral Anoxia and under paragraph b Inhalation of Fire Fumes
Circumstances of the Death
At some point during the night of the 10 to 11u of November 2010 the failure of the fridge freezers defrost timer resulted in fire that spread from the fridge freezer to the house whilst Mr Muthiah and his family slept upstairs. Fortunately awoke and efforts focussed on saving their children: Mr Muthiah's wife passed one of their two children to a neighbour who had climbed the front of the house to the front bedroom window: Their second child was rescued by another neighbour from a flat roof at the rear of the house. The London Fire Brigade recovered from on the bed in the front bedroom and Mr: Muthiah from the bathroom at the rear of the house. Mr and_ Muthiah were taken to hospital where Mr Muthiah died as a consequence of smoke inhalation in the fire at his home.
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