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82. The officer in charge at that time must, we think, have been aware, or at least apprehensive, that the fire could not be confined to the basement and might develop into a major fire taking the whole building. He should have been the best judge as to whether the fire was serious or not. Under those circumstances it is difficult to understand why he did not ask Mr. Ballantyne if everybody had been evacuated from the building : and, unless he received that assurance, give orders to see to it that all were evacuated, especially those on the upper floors. 83. Mr. Girling-Butcher, writing in the Trailer Fire Pump Manual, said : It is the first responsibility of the officer in charge to see that every person is clear of the building. If this cannot be established by inquiry he must immediately institute as complete a search of the building as possible, having regard to the state of the fire. The search is carried out at the same time as the fire-fighting arrangements are being organized, but takes precedence of the latter. In our opinion, this principle is not one which can be varied or neglected by the officer in charge of a fire. If it is to be left to the discretion of the officer in charge as to whether the principle should be observed or not, then, as a principle of fire-brigade operations, it is undermined. 84. The officer in charge himself, when questioned as to the steps the brigade should take, said : During the daytime, had it been an old people's home or a hospital, it would be the duty of a fire-brigade officer to see that every one was out. At night-time, in the case of residential quarters, boardinghouses, hotels, &c, it is our duty to make sure everybody had left the building. Biit at four o'clock in the afternoon, when everybody is awake to the fact that there is a fire in the building, it did not come to me to ask them to evacuate the building at that time. 85. The Superintendent of the fire brigade, when questioned on this point, said: — Q. ... do you think he (Burrows) was justified in having given no order to evacuate right up until the time of the brigade call, with all the trust that you have in him as an officer ? A. When he returned from the goods-lift round to the front, and if the position was as I pictured it, then that was the time he should have given the order to evacuate. Q. So at least you will agree he should have given the order some time prior to the brigade call ? A. Yes, just prior to the call. 86. It appears to us that, with a fire in a large building where there is normally a large staff, it should have been apparent to the officer that inquiry must be made thatsatisfied him complete evacuation had taken place, or else steps taken to see that evacuation in fact had taken place. In the case of a fire at night when the business was closed, he might reasonably assume that none of the staff were in the building, but when a fire takes place at a time when he knows the business is in full swing and staff on the premises, the obligation to see to evacuation is, in our opinion, imperative. . We think that failure to satisfy himself that evacuation had taken place, or to give orders for immediate evacuation, or actually send firemen to see that evacuation had taken place, was a departure from a principle of fire-fighting that should be observed by every brigade. OBDEB OF EEFEEENCE (3) Whether any special circumstances contributed to the rapid spread of the fire, and, if there were such circumstances, ivhether the fire hazard could have been reduced by the installation of five-prevention equipment or by any other means. 87. We have referred in the Introduction to the wall-linings of soft fibre boards ; the unenclosed lifts and stairways ; the lateral openings in walls that had become internal walls ; and the absence of sufficient fireproof doors. Each of these factors, and other factors which w T e will refer to, separately promoted the rapid spread of smoke and fire.

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