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20 May 2014, 16:24 | Updated: 30 March 2016, 13:50
A coroner has criticised the Ministry of Defence for a series of failures over the deaths of a Hampshire soldier and his colleague in a fire which engulfed their tent as they slept at Camp Bastion in Afghanistan.
Wiltshire and Swindon Coroner David Ridley said he would be making a 'preventing further deaths report' over the case of Privates Rob Wood, 28, and Dean Hutchinson, 23.
The MoD now has 56 days to reply in writing, giving details of actions that have been taken or are proposed to be taken, or an explanation as to why no action will be taken to prevent future similar deaths.
Mr Ridley recorded a narrative conclusion and listed eight areas where there was either a ``systemic failure'' or ``failure'' in the circumstances that led to the men's deaths.
The two soldiers, who served with the Royal Logistic Corps, were killed when fire swept through a logistical centre at Camp Bastion in Helmand province in the early hours of February 14 2011, the 10-day inquest in Salisbury, Wiltshire, heard.
They were sleeping in the tented Transport Troop office so they could respond more quickly when vital supplies arrived at the military base.
Eyewitnesses described smelling smoke coming from the area housing a 32in flat-screen TV, boiler and fridge, and seeing flames coming from cabling leading to the air conditioning unit.
Private Sikeli Ratu, who was woken by the smell of smoke, fled the canvas tent to raise the alarm and said he could hear Pte Hutchinson calling his name.
But there were delays in alerting the military fire brigade because soldiers at the scene did not know the emergency 222 number.
By the time firefighters arrived at the scene, the blaze had taken hold of the tent, with flames approximately 3ft high and only the metal tent poles remaining of the structure.
Fire investigators have concluded that the blaze started in the vicinity of the electrical appliances and quickly spread, igniting combustible materials stored nearby.
The inquest heard that both senior commanders and fire safety officers did not know the soldiers were sleeping on duty during night shifts.
Had they known, the fire risk assessment for the tent would have had to have reflected it, with separate sleeping areas and an unobstructed rear exit.
The ``unwritten rule'' for the troop was that the duty non-commissioned officer should have remained awake while the other soldiers slept.
Giving evidence, Pte Ratu, who was an acting Lance Corporal, conceded he should not have gone to bed but insisted he had told Private Apenai Bukarau to stay up - something Pte Bukarau rejects.
The inquest heard that Camp Bastion suffered from power cuts and there were also problems reported with the lights and air conditioning at the base.
Infrastructure contractor KBR was responsible for the maintenance of fire alarms, hard wired smoke detectors and the four-way blue domestic power units.
However, they were not responsible for maintaining battery-powered smoke detectors outside of the accommodation blocks or any appliances plugged into the power units.
But there may have been confusion about who was responsible for checking the smoke detectors in the Transport Troop tent.
Corporal David Williams, who was the troop's ``fire NCO'', insisted it was KBR's job but when presented with evidence to the contrary he conceded he ``may well'' have been mistaken.
He said he only carried out visual checks on the smoke detectors, which did not match the guidance published in his ``fire diary'' of how they were to be checked, which included a simple push-button test on the device.
Cpl Williams described seeing the boiler, TV and fridge plugged into a white four-way extension lead, which was then plugged into one socket of the blue domestic power unit.
Electrical items in the Transport Troop tent had not been PAT tested, although regulations stated it should have been done.
Other witnesses spoke of the dangers of ``daisy chaining'' multiple extension leads, which had been the cause of a previous fire at Camp Bastion.
The Transport Troop tent was also not listed on KBR's ``asset register'' of all facilities the company was responsible for maintaining.
The hearing also heard that in January 2011 members of the Transport Troop extended the rear of their 18ft by 24ft tent by 50% to house members of the Royal Electrical and Mechanical Engineers.
By doing so they filled the space set aside for a fire break and joined it to the adjacent Troop's Quartermaster tent.
The inquest heard that a new fire risk assessment should have been carried out as soon as the extension was built because it was longer than 27ft.
Captain Timothy Fitzgerald, Privates Hutchinson and Wood's troop commander, said there were plans to carry out a new fire risk assessment once they had annexed the recently vacated Quartermaster's tent.
The rear of the Transport Troop tent was not permanently sealed and could be opened by unzipping the fire retardant inner lining and undoing the toggles to the canvas door.
But the rear door to the adjacent Quartermaster's tent was tied up tightly and also padlocked, the inquest was told.
Since the tragedy a number of changes have been made by the Ministry of Defence and Army to improve safety for troops using tents.
Pte Wood, known as Woody, had become a father to a boy, Noah, shortly before he died. He was a driver port operator, posted to 17 Port and Maritime Regiment, and lived in Marchwood, Hampshire.
Pte Hutchinson, from Spennymoor, County Durham, was a driver and had seven years' service with the Army.
Mr Ridley listed seven ``contributory factors'' in the deaths of the two soldiers during his lengthy narrative conclusion:
``The systemic failure by the chain of command to communicate the occurrence of sleeping on duties at night to key personnel, such as the unit fire safety officer, as safety measures associated with this practice to all Transport Troop personnel.
``The failure to police the occurrence of sleeping on duties at night through the use of random checks.
``The failure to effectively check the working functionality of the nine-volt smoke detector located inside the tent where the fire started, resulting in it not being in working order at the time of the fire.
``The systemic failure to provide effective training, especially to fire NCOs, to identify the potential risk of the overloading of sockets and extension blocks.
``The failure to rectify the error in the December 2010 fire risk assessment, when it became known that sleeping was taking place within the tent in December 2010.
``The failure to request a fresh fire risk assessment following the structural alterations that took place in January 2011.
``The absence of the Transport Troop tent from the theatre asset register.''
Mr Ridley said that, considering all the evidence, he was able to conclude that the fire started as a result of the failure of either the wiring inside a white four-way extension socket or the metre-long cable attached to it, into which the 160-watt TV, 3,000-watt boiler and 380-watt fridge were plugged.
``Roderick Stewart, an independent forensic examiner, believes that either the extension block or the one metre cable failed as a result of overloading of that particularly appliance over time,'' Mr Ridley said.
``The cause of the fire was not, in his view, any of the three appliances connected to the extension block.
``There is no evidence before me of the extension block being tampered with in any way.
``I find, on the balance of probabilities, it was fitted with a 13-amp fuse. Mr Stewart was unclear as to why the fuse had not blown.
``What is clear is that the boiler, fridge and the television together exceeded the relative ampage of the extension block by about 20%.
``This would have caused the wiring either inside the block or the lead to degrade as a result of heat generated until it failed, resulting in arcing and sparks.
``Those sparks, I am satisfied, ignited the combustible products stored under the table and that area provided a constant fire source to ignite the tent.
``I am satisfied, more likely or not, that the degeneration of wiring inside the extension block appliance or its lead would have begun when the fridge was installed before Christmas 2010.''
Mr Ridley went on: ``Given the evidence that, on the morning of the fire, Private Ratu did not hear at any stage the alarm as he made his escape, I find it as fact that the smoke detector was not in working order at the time of the fire.
``I find it as fact that the rear exit of the Transport Troop tent was not a usable exit and at the time of the fire the tent only had one effective exit.
``The missed opportunities highlighted relating to the fire risk assessment more likely than not would have introduced additional precautions and safety measures, including a second exit and a working wired smoke detector.''