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Fire drill failure at a food ingredients site

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Fire drill failure at a food ingredients site

A 90-employee food ingredients site has one main production hall, a laboratory, and a two-storey office block. The last fire drill, six months ago, took 6 min 20 s to evacuate 74 people present. The roll call was inconclusive for 11 minutes because visitors had signed in at reception but not at the assembly point, and two contractors were unaccounted for. A fire door on the east corridor was propped open with a pallet. The alarm is a bell that cannot be heard in the noisy milling area, measured at 92 dB(A), where staff wear hearing protection. There is no alternative escape route from the lab store, and one member of staff uses a wheelchair. The fire risk assessment was last reviewed three years ago, before the lab was extended.

1. Evaluate the drill performance and identify the deficiencies that matter most.

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The drill exposed system failures, not just slow walking

An evacuation time of 6 min 20 s is not automatically unacceptable; travel distances, staffing and the fire scenario matter. The serious deficiencies are elsewhere.

  • Roll call failure. Eleven minutes of uncertainty means the site could not tell whether people were still inside. Visitors and contractors were not captured at the assembly point, so the accounting system failed at the interface where people are most vulnerable.
  • Propped fire door. A fire door held open with a pallet defeats compartmentation. Smoke and fire can spread through the opening, and the door may not close in a fire. This is an immediate life-safety issue.
  • Alarm audibility. A bell that cannot be heard in a 92 dB(A) area, where hearing protection is worn, is not a reliable warning. Staff may not know to evacuate, and hearing protection further reduces the signal.
  • Single escape route from the lab store. If the only route is blocked by fire or smoke, occupants are trapped. The lab extension may have changed the risk.
  • No personal emergency evacuation plan for the wheelchair user. The drill should have tested a specific plan, including assistance and a refuge if needed.
  • Outdated fire risk assessment. It predates the lab extension and has not been reviewed for three years, so it cannot reflect current layout, occupancy or hazards.

The drill should be treated as a failed test of the emergency arrangements, not as a box-ticking exercise.

2. Prioritise remedial actions with timescales. Justify the order.

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Immediate life safety first, then system fixes

Immediate (same day or before next shift)

  1. Remove the obstruction and secure the east corridor fire door so it closes. Brief the team on why propping is prohibited. This is a direct compartmentation failure.
  2. Establish a temporary reliable alarm for the milling area: visual alarm, flashing beacon, vibrating pager, or a procedure to stop machinery and signal evacuation. Do not rely on a bell that cannot be heard.
  3. Confirm a personal emergency evacuation plan for the wheelchair user, including a named buddy, route and refuge. Test it.
  4. Tighten visitor and contractor accounting: sign-in at reception and sign-out at the assembly point, with a named person responsible for the roll call.

Short term (within days to two weeks)

  1. Review the fire risk assessment, including the lab extension and the single escape route from the lab store. If the route cannot be protected, restrict storage or provide an alternative.
  2. Re-drill with the new alarm and roll-call arrangements, including visitors and contractors.
  3. Train staff and contractors on evacuation, assembly points and the prohibition on propping doors.

Medium term (one to three months)

  1. Install a permanent audible and visual alarm solution in high-noise areas.
  2. Improve escape route design or protection for the lab store.
  3. Set a fire-door inspection regime and a drill schedule.

The order is justified by the severity and imminence of the risk: alarm and escape come before documentation and training, because without them people may not receive warning or may be trapped.

3. Propose performance indicators and a method for testing whether the improvements have worked.

Read the worked answer

Measure what would fail in a real fire

Lagging indicators

  • Evacuation time from alarm to assembly point.
  • Time to complete a confident roll call, including visitors and contractors.
  • Number of unresolved discrepancies at roll call.
  • Fire-door defects found and closed.
  • Alarm audibility test results in high-noise areas.

Leading indicators

  • Percentage of staff and contractors trained in evacuation and assembly arrangements.
  • Percentage of visitors signed in and out at the assembly point during drills.
  • Frequency and quality of fire-door checks.
  • Percentage of personal emergency evacuation plans reviewed and tested.
  • Fire risk assessment review status and open actions.

Testing method

  • Run an unannounced drill and observe rather than coach. Use someone to act as a visitor and someone to act as a contractor to test the accounting system.
  • Time the roll call independently and compare it with the fire marshal's record.
  • Test the alarm in the milling area with machinery running and hearing protection worn.
  • Check fire doors after the drill and at random times.
  • Review the results at the safety committee and set a target for the next drill.

Judgement

A fast evacuation with an inconclusive roll call is not a success. The key indicator is confidence: can the site state, within a defined time, that everyone is accounted for? If not, the system has not worked, regardless of the clock.