Case studies

This chapter contains case studies giving brief descriptions of the events leading up to five disasters. It is important to remember that these studies were written with the benefit of post-disaster research, and with knowledge of inquiry investigations and report contents. The studies are not an attempt to give a complete description of the circumstances surrounding the events — fuller commentaries are contained in the various inquiry reports. The case studies are included here to put the current discussion into context by looking briefly at some events that can occur during the incubation period of a disaster. The descriptions highlight the fact that while technical factors are involved in disaster causation, social factors — including communications failures, interactions between people, economics, and politics — also play a major role. The five disasters are as follows: Coldharbour Hospital — a fire at a hospital containing mentally ill patients Dudgeons Wharf — a fire, and subsequent explosion, during demolition of a storage tank Fairfield Home — a fire in a residential home for elderly people Summerland — a fire at a large-scale leisure centre Taunton railway — a fire in a train’s sleeping-car