It can’t have been the easiest of tasks going to firefighter Mark O’Shaughnessy’s station locker to clear out his belongings days after his death.

On September 26th, 2007, O'Shaughnessy and Brian Murray, a colleague in the Bray, Co Wicklow, fire service, entered a burning building to check that no one was inside as the blaze took hold. Instead of saving the lives of others, though, it was they who perished when the roof collapsed, engulfing them in debris and smoke and flames.

Murray (46) left behind a wife and 15 children; O’Shaughnessy was single but with a long-term partner and although just 25, he had 2½ years fire service experience behind him.

The three who went to check his locker were O’Shaughnessy’s brother Eamon; Hazel O’Brien, his partner, and Keith Gordon, his best friend.

A few days before the fire, Eamon saw Mark at home, sitting at the kitchen table, writing something, but he had paid little attention. Now he was going to gather his dead brother’s belongings.

Because the key to O’Shaughnessy’s locker was on his body, or with the Garda after the blaze, a firefighter colleague at the station had to break it open. Inside were the clothes out of which he had changed before going to the fire and on top of them was a note, the handwritten one O’Shaughnessy had been jotting at his kitchen table a few days before.

"It was a list of his concerns, of what he thought . . . It was literally in his own hand, saying 'these are the problems'," Hazel said in an interview with The Irish Times.

The note referred to problems with the station roster, to a “lack of men” – firefighters expected to fight blazes and, sometimes, rescue people from burning buildings at not inconsiderable risk to themselves.

It continued, in aspirational terms: “We shall always be a minimum of 2 crews.”

Another line noted: “TRAFFIC – more and more we can’t get through the traffic quick enough in the appliance – How can we be expected to arrive at the STN in 13 min.”

Another part of the note referred to the minimum number of firefighters needed to constitute a proper – ie fully manned – crew. “What is the minimum?” the handwritten note queried.

Long-running campaign
O'Shaughnessy's note was essentially an aide memoire to himself. It was written on foot of a colleague's request to all Bray firefighters to write down what they felt was wrong with the service, part of a long-running campaign with station management and with the ultimate overseer of the service, Wicklow County Council.

O’Shaughnessy dealt with issues he and colleagues felt they had been grappling with for years. It was their view that the service was poorly managed and that they, the firefighters, were inadequately trained and equipped for what was being asked of them.

Those in authority to whom they conveyed their concerns had not, they felt, addressed them adequately; it fact, they felt they were not really listened to at all. Now two firefighters were dead.

On June 20th last, Wicklow county manager Eddie Sheehy stood outside Dublin's Criminal Courts of Justice building near the Phoenix Park. A full six years after the tragedy and after eight days of a trial for criminal responsibility, the council finally acknowledged much of what the firefighters had been saying – it was indeed guilty of multiple failures under health and safety at work legislation.

Suddenly, long before proceedings were expected to end and as expert witnesses for the prosecution were about to be called, the council changed its plea from not guilty to guilty.

It now admitted that it indeed failed to provide firefighters with proper training, adequate back-up, adequate control and communication systems during emergencies; clear rules of engagement for fighting a blaze and adequate systems for dealing with emergencies; also that it had failed to review risks on a regular basis to make sure, insofar as was possible, that it was looking after the wellbeing of its fire fighters.

Despite the admission of guilt, Sheehy made a statement outside court in which he asserted: “The deaths [of O’Shaughnessy and Murray] . . . were not as a consequence of the breaches of the Act of 2005 . . . Wicklow County Council again extends its deepest sympathy to the families of the deceased men, two very dedicated and brave firefighters.”

A statement issued simultaneously on his behalf by a public relations company asserted further that an amendment to one of the charges “acknowledges that the deaths of Sub-Officer Brian Murray and Firefighter Mark O’Shaughnessy were not as a consequence of the breaches of the Act of 2005”.

Listening to Sheehy’s comments, the families of the dead firefighters heard, again, what they regard as hollow platitudes of sympathy from a council employer that had repeatedly failed to live up to its responsibilities.

Others sources close to the multiple investigations into what happened were also surprised at Sheehy’s behaviour.

“It was the wrong tone,” said one senior source. “What did he achieve? He upset the family.”

Six-year saga
The six-year saga that led to yesterday's sentencing of Wicklow County Council to a fine of €350,000 plus costs of some €96,000 began at Adelaide Terrace off the Lower Dargle Road in Bray. It is a town and hinterland of some 32,000 people in north Wicklow whose many empty retail outlets speak of the effects of the recession.

Before September 2007, when the building was destroyed by the fire in which Murray and O’Shaughnessy died, the single-storey corner site at Adelaide Villas and Park Court had been home to several businesses, including at one stage, Haughton’s, a paint company.

By the time of the blaze, however, it was semi-derelict and unoccupied – save for the old car tyres, discarded fridges, bits of bedding, paper and household waste that had been dumped inside.

One of the previous occupants had installed some rather unorthodox insulation. Beneath the corrugated iron roof and in the rafters that held it up, old wooden pallets had been inserted and stuffed with newspaper – presumably in a bid to achieve greater winter warmth for those working there.

The dumping and related vandalism concerned the owner who in September 2007 asked her nephew, Garreth Nolan, to have a welder, Aiden O’Neill, seal shut a large sliding metal door to the side of the disused factory in the hope of stopping unauthorised access.

Nolan and O’Neill went to the factory at about 10am on September 26th. To power their equipment, they cadged access to electricity from a nearby house and set about their work, sealing the large metal door first from the inside, then the outside.

Sparks everywhere
One of the residents, Bernadette Cash, was driving by and was struck by what was going on. "There was sparks everywhere," she later told investigators into what happened. "I had to slow down driving because of the sparks."

The investigators concluded that the fire which was about to ignite came from the same sparks.

"The cause of the fire was most probably due to the ignition source being the production of a spark or sparks from unprotected welding activities and falling among adjacent combustible materials that had been dumped within the yard," concluded a June 2009 report by Dr Peter Mansi, then manager of the fire investigation group of the London Fire Brigade.

Mansi was asked to investigate the fire by the Health and Safety Authority (HSA), which ran a parallel and to some extent overlapping investigation with the Garda. Their inquiries led to unprecedented Garda raids on Wicklow County Council offices and, extraordinarily, the formal arrest and questioning under caution of senior members of the local authority’s administrative staff, including county manager Eddie Sheehy, and senior assistant chief fire officers Joanne O’Connor and Tadgh O’Shea, and former chief fire officer Jim Dunphy.

By 10.25am on September 26th, O’Neill had finished his welding and he and Nolan departed the area. Within 15 minutes, though, at 10.40am, emergency calls were being made to Bray Fire Brigade.

The first was from a building site worker, the next from a man out walking who stopped a council truck with three occupants and asked the driver to call the brigade, which he did, via his supervisor, Paul Wogan.

Loud bangs
The men in the truck heard loud bangs, or explosions, from inside the burning disused factory. At about the same time, the building site worker again contacted the fire brigade but, oddly, was deemed to be calling to say the fire was going out.

Calls to the brigade were taken by fire control operator John Whiston, who was working alone, as was usual. Whiston’s job was to take emergency calls in the station’s watch room, assess their seriousness, and respond accordingly.

“I have had no formal training for my job,” he later told investigating gardaí. “I have learned from ongoing experience . . . I have received no formal training in the assessment of calls.”

Such was the seriousness of the unfolding situation, that Whiston shortly sought help in dealing with the emergency from two clerical officers at the fire station and from the canteen tea-lady.

When Paul Wogan came on the line, Whiston told him the fire had gone out, a view based, apparently, on what the building site worker allegedly said in his second call. Wogan assured Whiston that it had not; there was “a lot of smoke” coming from the disused factory, he said.

At 10.43am, Whiston used the Bray brigade's paging system to alert the duty crew of the part-time service that there was a fire.

Tender dispatched
A tender was dispatched by 10.50am. On board were station officer Jim Maguire, who was in command; Tony Horan, an experienced firefighter but whose training did not include compartment fire behaviour; Martin Lyons, the driver and pump operator; and Brian Murray and Mark O'Shaughnessy.

About this time, a woman rang the station demanding to know why, since she alerted the brigade “20 minutes ago”, there were still no firefighters at the scene. Whiston told her he had not “received any calls from her about the incident”.

“I’m sure I didn’t receive any call from a female,” he later told Garda investigators.

Peter Mansi’s report states that the woman’s call to the station, which she asserts was her second, was witnessed by another firefighter, Eddie McCann, “who had just arrived on duty and believed that the call was not ‘friendly’,” wrote Mansi.

“I heard him [Whiston] talking to what I believe was a woman,” McCann told gardaí. “I think it was a woman because the last thing he said on the phone was ‘you do that, love’.

“The conversation between them did not sound friendly. When he hung up he said ‘Jesus’ and walked out of the room again.”

By this time, the initial fire tender and crew dispatched had arrived at the scene of the fire. Their first priority was to check that no one was inside the building. Murray and O’Shaughnessy put on their breathing apparatus and found a way in, via the corner entrance door as opposed to the metal sliding door behind which the fire was blazing.

They entered, equipped with a brand new foam-based fire-fighting system. Neither, however, had been trained in its use and, as equally untrained colleagues were to discover, foam operated totally differently to water in a real-life, confined, firefighting space. Also unknown to them, the hose was fitted with an incorrect nozzle which rendered it ineffective.

Inside the building, the fire had taken a firm grip. The flammable mix of debris on the floor – old tyres and timber, mainly – eventually ignited the DIY newspaper insulation and wooden pallets in the rafters, creating a lethal furnace of extreme heat that soon brought the roof down on the two firefighters.

As events were taking their dramatic and tragic turn at the fire, back at the station, news of the emergency was spreading. McCann commandeered the station’s four-wheel drive and headed down to the fire alone to help as the call went out for the station’s second crew to join the fight.

Within another minute, the call went out to Greystones, another part-time service in the nearby seaside town, seeking help from a third crew.

More firefighters began to arrive at Bray station but there was no driver for the second tender and they had to hang around waiting, hoping for a lift from Greystones. But the radio message alerts to Greystones – one at 11am and again at 11.07am – were apparently not received due to faulty equipment.

Eventually, at 11.10am, Whiston telephoned Greystones subofficer Derek Archer, using an automated, double-voice prompt system that sets off a pager alert. Within three minutes, Archer called Bray and said he did not get the previous but, nonetheless, he and his crew were on their way.

By now, the second group of firefighters in Bray had given up waiting. Instead, led by Ronan O’Sullivan, they commandeered the station’s hydraulic platform tender and headed down to the fire.

At 11.32, Greystones firefighters arrived at the scene.

Concern growing
At the fire, concern was growing for Murray and O'Shaughnessy who had failed to return from the blazing building.

Initially, there were insufficient crew on hand to go in after them: Jim Maguire had to remain out as he was in charge of the whole operation, Martin Lyons had to man the pump and Tony Horan could not go in on his own.

When McCann arrived, he put on breathing apparatus and with Horan got to work. McCann smashed a narrow window high on an external wall to let smoke escape and cut through another entrance door to give greater access.

Maguire told him to start using the hose, which was attached to the relatively new foam-based system known as Cafs, or compressed air foam system.

“I had never used the Cafs system in a building before the fire,” McCann told investigating gardaí. “I have had an introduction to Cafs when the system arrived but I have not had specific Cafs training.”

On July 3rd, three months before the fire, Browns Coachworks of Lisburn, Co Antrim, delivered to Bray a spanking new fire tender equipped with the Cafs system.

On delivery, firefighters were given no more than a familiarisation talk about the new machine. They were shown each lever and knob and told what the levers and knobs operated – but not how to operate them; not the circumstances in which to use the system and when not to use it.

There would be someone over soon from Britain to train them, said firefighters who spoke to The Irish Times on conditions of anonymity following a brigade order, dated April 29th, 2013, by the current chief fire officer, Aidan Dempsey, banning direct contact with the media.

Foam operates quite differently to water when used against fire. With water, firefighters typically attach a diffuser to the nozzle of the hose. When the water is pushed through it under pressure, the effect is to create a fine spray of water molecules. This breaks up the smoke, cools it and so the temperature drops.

“You keep doing that and you fight your way to the seat of the fire and you can put it out,” explained one firefighter. With foam, though, “it’s like a blanket”. It spews from the open pipe and in effect smothers the fire. It is highly effective when the seat of the fire has been engaged, often outdoors, in a blazing vehicle, for instance.

However, for Horan and McCann inside the blazing Bray building, crawling first on knees, then on their stomachs, the foam spray was not only ineffective, it actually made matters worse.

“On my right, there were flames licking through the smoke so I tried to pulse [attack with short bursts] the dark smoke on the left,” McCann told gardaí.

“I opened the branch [hosepipe nozzle] and it had no effect other than it made it hotter because the steam from the foam was coming back at us, so I tried it on the right to stop the flames coming towards me. It had no effect – same again, more heat.

“At this stage I was really burning myself. I could feel the heat coming up through me, my arms were burning so I put the branch on the ground and sprayed it and the area in front of us because where we were lying was on fire.”

Repeatedly, McCann and Horan attacked the fire with foam and water but were beaten back each time, but they kept re-engaging, even when in one instance, McCann’s clothes ignited in the intense heat.

Numerous colleagues from Bray and Greystones were now at the scene. Eventually, the bodies of their colleagues were found and both were pronounced dead at the scene at 12.45pm.

Inquiries
Two parallel inquiries were launched into the circumstances surrounding the deaths of Murray and O'Shaughnessy – one conducted by the Health and Safety Authority, the other by the Garda.

The first was led by Kevin Broderick, an engineer by profession and a long-standing inspector with the HSA. The Garda inquiry was led by detective garda Maurice Hickey from Bray station.

The families and colleagues of the dead men are unstinting in their praise of Broderick and Hickey and of Hickey’s family liaison colleague, Mervyn Butler. However, they are equally critical of managers inside Bray station and hostile towards Wicklow County Council, the overseeing body of the county’s fire service, and of the county manager Eddie Sheehy.

Their views on their managers and senior council officials are born, they say, of years of frustration pointing out what they see as deficiencies with the service and their feeling of not being listened to. Much of what they have to say is unprintable.

Broderick and Hickey worked in partnership, running parallel but separate inquiries. The HSA inquiry was done under the Safety, Health and Welfare at Work Act 2005. The garda worked under the Non Fatal Offences Against the Person Act 1997.

It was unusual for gardaí to be working so intimately with another State agency, sharing information yet remaining separate. A high level of trust, not always seen between State agencies, was required and in this instance it seems to have worked.

The two sides met regularly. They would review their interviews and documents together, discuss where the investigation needed to go, agree who would go where and do what, and then do it.

Raid on offices
At 10am on February 23rd, 2010, a team of gardaí arrived at Wickow council's headquarter offices in Wicklow town and sought access. Once inside, they seized paper files and computers. The computer hard drives were later examined by experts in erased data retrieval.

In May and June, four officials were arrested – county manager Sheehy and three members of the fire service. The case proved to be “extremely challenging”, according to one well-placed source. It was complex, involved a lot of forensic work and was the subject of political debate.

“We could not say that co-operation was not forthcoming,” added the source, “but co-operation is on a scale and Wicklow were not at the full co-operation level. They never behaved in a manner that was illegal but at every turn there were lawyers riding shotgun.”

Garda sources support this assertion, noting that while there was co-operation “within the law”, it had proved necessary to arrest people and question them under force of a formal caution.

Not long after his arrest, Sheehy attended a conference organised by the Irish Public Bodies Mutual Insurance, a company that specialises in large-scale public liability insurance and has strong links to local government.

By coincidence, it is chaired by George Jones, a long-standing Wicklow councillor. The conference was attended by county managers and other key people in local government concerned with insurance.

It took place in the context of the Wicklow arrests and the implications of a March 2010 case in which, following the death of a truck driver, a Clare County Council engineer was given a 12-month suspended jail sentence for failing to identify the hazards and assess the risks of the workplace, so as to ensure, insofar as reasonably practicable, the safety of employees.

Based on Sheehy’s specific experience, although not relayed directly by him, delegates were told of the emotional effect of being arrested and of having to remove one’s tie and shoelaces before being placed into a Garda station cell. “He found the whole experience very traumatic,” the source said.

Peter Mansi, who had 30 years’ experience as a firefighter and subsequently as a fire investigator, thought the Bray case would – should – lead to what he terms a revolution in the Irish fire service.

"I really thought it would," he said in an interview this week with The Irish Times. "From what I know of the Irish fire service, it seems to be about 20 years behind over here [in Britain] with regards to operational policies and procedures and the training and so on."

Below standard
He assesses what went on in Bray station watch room on the day of the fire as far below standard for a modern fire service. The call-out function has since been removed from Bray and is now channelled through Dublin Fire Brigade in Tara Street.

“It should be as it is [in Britain],” he asserts.

“You get a fire engine there with at least four to five people on it within five minutes . . . The control officer [in Bray] decided at one point he thought the fire was out and didn’t send anybody and then [after another call in] . . . there was no second driver available . . .

“So it’s all done like on a shoestring and seems to be almost run on goodwill. It is old fashioned and in 2007 when this occurred, even for an organisation that might be struggling financially, to be able to mobilise around the stations within a county should have been addressed without using an old-fashioned pager system.

“London Fire Brigade still use a pager system, don’t get me wrong, but it [Wicklow’s] obviously wasn’t working because Greystones never got the message.”

He also queries Wicklow County Council’s conduct in initially pleading not guilty, only to change plea to guilty midway through a trial and before independent witnesses could challenge them.

“It was a shame that they [the families and firefighters were] put through all that at the trial and when it came to their [Wicklow’s] turn, they changed their plea and avoided it.”