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In re the Death and Fire Inquiries Act [2004] SBMC 1; CMC 1097 of 2004 (9 July 2004)

IN THE SOLOMON ISLANDS
IN THE CENTRAL MAGISTRATES COURT

Case Number 1097 of 2004

IN THE MATTER OF THE DEATH AND FIRE INQUIRIES ACT

AND IN THE MATTER OF A FIRE WHICH OCCURRED
IN HONIARA ON 28^TH JANUARY 2004

FINDINGS OF THE INQUIRY

As acting Chief Magistrate I convened an Inquiry pursuant to section 11 of the Death and Fire Inquiries Act [Cap 9] in respect of a fire which occurred in Honiara on 28^th January 2004. The fire destroyed three buildings on Mendana Avenue and I shall refer to them throughout this report as the South Seas Traders building, which was on the eastern side of the fire scene, the Radio Techniques building, which was on the western edge and the Victory Enterprises building which was sandwiched between them. The three buildings housed a number of businesses. The ones which will be most mentioned in this report are the South Seas Restaurant, housed in the South Seas Traders building and the accounting firm of Goh & Partners housed in the Victory Enterprise building.

The Inquiry took place over a number of days, namely 17^th , 18^th, 24^th and 25^th June and 1^st July. I was assisted, and I am very grateful to him for his help, by the learned Director of Public Prosecutions, Mr Francis Mwanesalua. I am also grateful to Inspector Bruce Terry for his help.

In the second half of the inquiry Mr Dennis McGuire of Messrs Sol Law appeared on behalf of QBE Insurance Ltd.

The purpose of the inquiry was, in the words of the Death and Fire Inquiries Act, to inquire, “.... into the cause and origin” of the fire. To that end I heard from the witnesses set out in Appendix A. I read the evidence of those witnesses listed at Appendix B. I had access to statements made by all of the witnesses listed in Appendices A and B. I also had access to the exhibits listed at Appendix C. In addition to those exhibits I was given a CD containing digital images taken by several persons and, although it was not formally exhibited, I had seen a short video taken by Assistant Commissioner John Lansley at the time of the fire. Inspector Terry helpfully provided a Power Point presentation showing several of the digital images. I should perhaps at this point mention that legal history was made in this Inquiry when I heard evidence from Mr Coulter and Ms Young over a live video link from Canberra. It is, as far as I know, the first time that evidence has been taken in this manner in this jurisdiction.

After considering all this evidence I am able to report my findings into the cause and origins of the fire. To be perfectly frank, very little can be said about the cause of the fire. I will return to this point later. As to place of origin, certainly some of the evidence I heard, in particular from Kyaw Min Soe, Joseph Na’amana, Jonathon Thegna and John Ao leads me to conclude that the fire originated in the offices of Goh and Partners. Honiara is a small town and I am aware of the uninformed opinion of some people which circulated soon after the fire that it started in South Seas Restaurant. Having heard the evidence I am certain that the fire did not start in the South Seas Restaurant and I find that it started in the offices of Goh and Partners and most likely in the store room or kitchen which were situated in the south eastern corner of Victory Buildings.

There is no doubt in my mind about the origin of the fire, that conclusion is inescapable after listening to the eye witnesses. In addition the forensic evidence of Ms Young is compelling. Witnesses saw, “smoke coming from a point 1 or 2 metres in from the rear of Victory buildings”, [Mr Soe]; “smoke from Victory Enterprise building, high up on roof line, on the side not the back”, [Mr Na’amana]; “Victory Enterprise building was burning, smoke coming out of the 2^nd window at the back’”, [Mr. Thegna] and “I..... saw a flame coming out from the east side of the Victoria(sic) Enterprises building where it came out of Goh & Partner Office”, [Ms Loke]. Some of these witnesses tried to put out the fire using a garden hosepipe and a ladder and had a very close view of where the fire started.

Mr Ao describes how he was in the South Seas Traders building in the South Seas Restaurant moving pictures and furniture away from the wall adjoining the Victory Enterprise building. He did this with the help of two RAMSI officers. At that time, this is approximately 18:00 hours, the fire was well established but there was no sign of any fire inside the South Seas Restaurant or the South Seas Traders building.

Ms Young in her evidence describes her examination of what was left of all three buildings. She is an experienced forensic scientist and has had four years practical experience in the investigation of fires. She describes doorframes in the downstairs part of the Victory Enterprises building being more burnt at the top than the bottom. She describes the buckling of steel girders in the Victory Enterprises building, this is quite visible in the photographs in album referenced FH040014, and how those on the eastern side showed more heat damage. In her written report she says, “In one section located just below the original position of the kitchen, the beam had detached from the framework, indicating severe and prolonged heat in this area”.

In her conclusion Ms Young says, “the apparent Area of Origin of the fire was upstairs in the ‘Victory’ building..........in the general vicinity of the kitchen and storeroom”. In her oral evidence Ms. Young had no reason to alter this conclusion.

As to the cause of the fire Ms Young says in her conclusion, “Due to the severity of the fire damage and the amount of time it was burning, a more exact location, or Point of Origin could not be established. Because the point of origin could not be located, the cause of the fire could not be determined”. She does say elsewhere in her report that, ”Areas of debris downstairs in the ‘Victory’ building were searched”, but she goes on to say, “Nothing of significance was located”, and, “No ignitable liquid odours were detected”. An examination of electrical fittings by two electricians led to a conclusion that no findings could be made as to whether an electrical fault caused the fire but such a possibility could not be ruled out.

The forensic examination by Ms Young and her conclusions are very persuasive in respect of the origin of the fire but unhelpful as to the cause. I do not intend that as a criticism of Ms Young in any way. Huge advances have been made in the field of forensic science and with the techniques now used and the skills applied by forensic scientists amazing results are often possible. It tends to lull us into a false impression that forensic scientists can solve any puzzle. Given the prolonged ferocity of this fire I would have probably been very surprised if Ms Young had been able to provide any firm conclusion as to its cause.

I am aware that QBE Insurance Ltd also arranged for a very detailed forensic examination of the fire scene by their own experts. I have not been able to see or make use of any report which resulted from that examination. I asked Mr McGuire if his clients would release a copy of any report. Not surprisingly, I was informed that QBE would be claiming legal privilege in respect of such report or reports. They cannot be criticised for adopting that stance. It is right and proper for them to reserve their position given the very distinct possibility of litigation following this fire. If there is a report and it does eventually become public and if it causes me to change any of the views expressed in these findings then I can, and will, reconvene the Inquiry and add to these findings.

Having reached this stage it could be said that the purpose of this Inquiry has been fulfilled. However, in view of some of the evidence I heard and read I feel I am bound to make further comments.

First, the use of the telephone for the emergency number 988. I was able to obtain a report from Solomon Telekom Co Ltd which detailed the calls made to 988 during the month of January 2004. It ran to 28 pages, each page detailing approximately 50 calls. That means there was approximately 1400 calls to 988 between 5^th January and 30^th January. Of those calls over 90 of them lasted longer than 10 minutes. 46 were in excess of 20 minutes duration, 8 in excess of 30 minutes and 1 call at 21:43 on 18^th January from number 21381 went on for an incredible 55 minutes plus. It is obvious that the majority of these calls have nothing to do with emergencies. When these calls are being made it means that the public are unable to report emergencies. This abuse of the telephone is putting property and lives at risk. It is criminally negligent. What if the call on 18^th January had been made 10 days later at 17:30 instead? What that would have meant is that the fire could not have been reported to the emergency services until well after 18:30 hours.

I am therefore going to bring this abuse of the telephone to the notice of the Fire Authorities and the Commissioner of Police by sending them a copy of these findings and a copy of the report from Solomon Telekom Co Ltd. Those who are abusing the telephone service can be identified and dealt with accordingly. I am doing this not just to stop the abuse but, more importantly, to prevent any further risk occurring to the public as well. I hope that action is taken before lives are lost or property destroyed because of the abuse.

Secondly, I am bound to note that there were no real contingency plans to cover a situation such as that which arose on 28^th January. The only fire tender available in Honiara had been sent to Tetere. The use of the fire tender for this purpose has to be questioned in the first place because it is clear from happened that day that it had implications which the authorities did not consider. In any event the fire tender broke down on it’s way back to base. That meant there was no cover for Honiara. I heard that there was an “arrangement” with the Shell Company fire fighters but it appears to be very informal and ad hoc. I would suggest that the arrangement needs to be put on a formal footing.

There is no doubt that the Shell Company fire fighters got involved on 28^th January and it needs to be put on record that but for their efforts the we would have had a catastrophe of major proportions. The use of their equipment, their provision of a water supply and the manpower they made available probably prevented the whole block from South Seas Traders westward to the Church of Melanesia buildings from being destroyed in the fire. The point is though that they were not involved as early as they could have been. I heard from the Guadalcanal Provincial Police Commander. He became aware of the fire just before 18:00 hours. At one stage he went over to Shell Company to ask for their help and he was informed that the request had to come from the Royal Solomon Island Fire Service. He said that he even started to beg for their help and it was only after that point in time that he saw movement. It is not known whether this was a result of his efforts or the result of a call from the Fire Services or because Shell Company could then see the scale of the fire. This must have been 5 or 10 minutes after 6. The first report of the fire that can be identified is a call at 17:40 hours. Why then did it take 20 minutes or more for a request to be made for Shell Company’s assistance or for them to become involved? If a formal arrangement had been in place then they may have been able to begin fire fighting efforts some 20 minutes earlier.

Similarly there was “an agreement” between the Fire Authorities in Honiara and the Civil Aviation Fire Service based at Henderson that the latter would assist the former if needed. The Fire Authorities must have realised on 27^th January that they were vulnerable with their tender broken down and stuck out at Henderson. Some contingency plan should have been made but we know that the Civil Aviation fire tenders were not called out until 18:10 hours, again 30 minutes after the first reports. What is also incredible is that I learnt that there was no way for the Fire Authorities in Honiara to directly contact the Civil Aviation base at Henderson. The Civil Aviation team had to be alerted to the situation by a telephone call via the public telephone in the domestic terminal building.

Thirdly, I heard about the poor state of the equipment used by the Fire Authorities. Hoses and fittings were old and broke down under pressure. I mentioned in the Inquiry that had just one Government Minister given up his overseas per diem for two days then the Fire Authorities could have purchased a brand new 30 metre length of hose. Some may accuse me of being flippant in saying that but I believe it to be a point worth making.

I am aware from my involvement in another committee that a detailed review of fire services in Solomon Islands has been completed and recommendations made. That, to my understanding, was over 6 months ago. I would venture to suggest that the deficiencies revealed in that report and the problems that were highlighted by the fire on 28^th January should mean that immediate action is taken. Some of the basic problems need to be sorted out right now and this is not perhaps a time for leisurely, detailed and considered reflection about what needs to be done.

Part of the remedial action that needs to be taken is in respect of the provision of adequate fire hydrants. I heard from the professional witnesses that there are hydrants in Honiara but that there are too few of them and those that do exist are unable to supply an adequate water flow for fire fighting purposes. I repeat the comments I made during the inquiry that I consider it negligent in the extreme that those responsible for the provision of hydrants and their maintenance clearly have not carried out their duty. Urgent action needs to be taken now.

Next, I would like to touch on the question of the behaviour of the crowd that gathered. I heard evidence about some of the crowd throwing stones and other missiles at the Police who were trying to maintain order. I also heard that some of the stones may not have been directed at the Police but were thrown in some kind of attempt to break windows so as to “help” fire fighters direct water from hoses onto flames inside the buildings. I would question whether such “help” is desirable. From my, admittedly limited, knowledge of fire fighting techniques I was under the impression that it was not a sensible thing to do to suddenly expose a fire in a contained area to a supply of oxygen through, for example a broken window or opened doorway.

That however is not my main concern. I have to say that even if only one stone was thrown at the Police then it was one stone too many. It is unbelievable that some one would act so irresponsibly by attacking police officers who were trying to ensure the safety of others. I would ask that if anyone can identify those responsible for throwing missiles at the Police then they should report them either to the Police or to me. The actions of those throwing missiles could have put lives at risk and those actions should be seen for what they are, apart from crass stupidity, namely criminal behaviour.

There was also a suggestion circulating at the time of the fire that some people in the crowd may have been planning to loot the buildings that were on fire or about to catch fire. I have heard no evidence of looting taking place or even of attempts to loot. Quite the contrary, some members of the public actually tried to assist in the fire fighting efforts. In any event, looting is not a problem which only affects Solomon Islands. I heard from one RAMSI officer, who has attended several fire incidents in Australia, that looting had taken place during and after those incidents. The only protection against such behaviour is adequate and effective crowd control. On 28^th January the crowd was controlled and RSIP and RAMSI personnel should be commended for their actions in that respect.

Another issue which must be raised following this fire is the complete lack of adequate legislation dealing with fire safety. There is no legislation to control the design and construction of buildings in relation to fire prevention. This may not be a major issue in 99 % of the Country, in the rural areas, but as Provincial centres begin to develop and as Honiara continues to grow it is a problem which must be addressed. Whilst I heard no evidence to suggest that the design of any of the buildings involved in the fire contributed to the spread of the fire, it stands to reason that without proper control many buildings will be “substandard”.

There are no laws dealing with the installation of smoke alarms, sprinkler systems or even basic fire alarms. In many countries even private dwellings are subject to regulation. In Solomon Islands there are no regulations for houses let alone commercial buildings or buildings used by the Public. It has been proven without any doubt in other Countries that the requirement to have proper fire safety systems and their installation has saved lives and has lessened the damage that fire would otherwise have caused. It is not difficult to believe that a smoke alarm system may have resulted in this fire being discovered at a very early stage when it may even have been possible the people in the building to put it out by themselves. A sprinkler system may have stopped the fire even reaching that stage.

Legislation could also cover the problem of rubbish burning. You can wander around Honiara on most days and see rubbish burning at the side of the road. In this Inquiry we heard about the regular burning of rubbish in Cluck Alley, the alley to the south of the fire site. On 28^th January when people smelt smoke they did not immediately think of fire. It is one of those small ironies that arise in real life that it is possible that one of the first people to smell smoke from the fire on 28^th January was actually the wife of the Deputy Director of Fire Services. She mentioned the smell to a colleague who was not overly concerned because rubbish burning was a regular occurrence and such smells were common place. I realise that by calling for controls on the practice of burning rubbish I maybe compounding another problem, that of public health. Until the proper authorities provide and maintain a regular rubbish collection people have no other way of disposing of their garbage.

The most difficult aspect about the fire incident on 28^th January to comment on is the apparent breakdown in cooperation between the various personnel who attended. The statements by Mr Aliga, Mr Kuma and Mr Koloni talk of being threatened and physically manhandled by RAMSI officers. There are comments by RAMSI personnel about firemen standing around without any real idea on how to fight the fire. Orders issued by one officer were countermanded by another. There are diametrically opposing opinions about the effectiveness or the appropriateness of using water drops from a helicopter to fight the fire. On one side we have descriptions of the water drops being very effective in cooling the heart of the fire thereby making it easier to fight from the ground. On the other side we have complaints that the use of the helicopter had no effect other than to supply more oxygen to the fire which made it worse. We heard evidence that fire fighting on the ground was suspended for 15 to 20 minutes during each drop which allowed the fire to regain intensity.

I am not qualified to make a decision on these technical questions. I heard no independent expert evidence which would assist me in making those kinds of decisions. All I would say is that after hearing evidence from a number of people I tend to accept that there were no long delays between individual bombing runs by the helicopter. I tend to accept that the water bombing did help reduce the fire’s intensity.

The evidence also revealed a total lack of communication between The Royal Solomon Island Fire Services and RAMSI personnel. Each seems to have had it’s own “Control Centre”. Neither was, apparently, known to the other. There was no unified command structure. There are a number of reasons why this situation seems to have arisen. RAMSI personnel seemed to have reached a conclusion very early on in the incident that local fire fighters were incompetent and ill equip to deal with the fire. The Solomon Island Fire Services personnel also seem to have reached an early conclusion that RAMSI were interfering where they shouldn’t. RAMSI say they couldn’t find anyone who was in charge of the Royal Solomon Island Fire Services and Royal Solomon Island Fire Service say they didn’t really bother to look for anyone who was controlling RAMSI and other personnel. Assistant Commissioner John Lansley was present during the incident. RAMSI made contact with him and worked with him. The Deputy Director of Fire Services said he was not aware that Assistant Commissioner Lansley was on the scene and in fact, “Would not recognise him if I saw him”. Clearly there was fault on both sides, a lack of understanding of the others point of view.

These are my personal observations they are not facts proven conclusively by evidence. All I can say after hearing all the evidence is that, for whatever reason, there was a lack of cooperation and it is possible that it contributed to the spread of the fire. I say possibly, not probably.

Conclusions

Having regard to all the available evidence I regret that I am unable to reach any conclusion as to the cause of the fire. There is no evidence that it was started deliberately. It is likely that it was caused by some accidental but indeterminate event.

All the evidence leads to the inescapable conclusion that the fire originated in first floor area of the Victory building and more precisely in the region of the kitchen or store room of Goh and Partners office.

The fire spread to the extent that it did because of the lack of proper fire fighting equipment, in particular working, serviceable fire tenders. I am also bound to point out that the Deputy Director of Fire Services did not have the use of a telephone and that he had nowhere to set up a readily recognisable control centre (e.g. a vehicle clearly marked as such). As a result it was difficult for him to communicate with anyone.

The incident has brought into stark relief major deficiencies in the Royal Solomon Island Fire Service. It is my view that the Government should immediately adopt and implement the recommendations made in the report by Mr Jurgens from the New South Wales Fire Brigade.

I would recommend that the town Fire Service, the Civil Aviation Fire Service, Shell Company and RAMSI consult and draw up clear and practical protocols and agreements to guarantee that all resources can be made available and quickly used to fight major fires such as that which occurred on 28^th January.

The evidence given to this Inquiry revealed that the provision of ground fire hydrants is hugely inadequate. The few that are available for use in the commercial centre of Honiara proved to be useless for fire fighting purposes. The Government, together with SIWA, must take immediate action to remedy the problem.

This inquiry has also revealed the need to take urgent action to introduce proper and comprehensive fire prevention legislation. In particular in regard to the design and construction of commercial buildings and those used by the public.

R D Chetwynd

9^th July 2004

Appendix A

Kyaw Min Soe
Joseph Na’amana
Jonathon Thegna
John Ao
Betsy Kuma
Robert Kemekesa
Karen Noda
Nauna Tomasi
Gift Akwai
Ken Chan
Nester Koloni
Peter Aoraunisaka
Fredy Pelebo
Tracy Young
Harry Thomas Hains
Brad Coulter
Brock Aliga
John Koloni

Appendix B

Sally Didia
Cathy Dawn Ladoga
Hellen Sifo
Francis Mui
Armstrong Lomilo
Gorethy Loke
Joyline Liolea
Cain Waokea
Ezekiel Porai
Brendon Akoso
Robert Siaw Kee Goh
Yolalande Zta Jordan
Doris Vakola
Rimilo David
Peter Wawane
Esmy Magu
William Gigini
Andrew Manepora’a
Andrew Andressen
Edward Horia
Elna Tati
Unity Sua
Eric Raraua
Sister Veronica Saina
Sister Anthonia Tarina
Lisa Nicholson
Rodney Kuma
Chris Woods
Gabriel Havimei

Appendix C

Photographs Forensic reference FH040014 (Gareth William)
Photographs Forensic reference FH040014 (Lisa Nicholson)
Photocopied photographs
Photographs taken on January 29^th 2004
Certificates of Insurance for Goh & Partners (x2) [QBE Insurance], George Wong Kin See [Tower Insurance] and Technique Radio Centre [QBE Insurance]