The firefighters, Anne Kregel, Raymond Soyer and Egbert Ubels entered the building not knowing that a layer of highly combustible smoke and gas had built up under the roof.
The municipal authority requested that the Vereniging voor Brandweerzorg en Rampenbestrijding (Dutch Association for Fire Service and Disaster Relief) form an independent Committee of Inquiry.
The committee reported: “The sandwich panels used for the roof construction meet the legal requirements for this type of building with regard to the flammability and/or fire development.
These panels comply with the legal requirements that apply to such a building with regard to flammability and/or the spread of a fire, but at the same time they also present a major risk: if the panels are sufficiently heated, the polyurethane present will lead to gas emission, flammable and toxic fumes will be released.
The most important reason for this is the absence of an effective and well-practiced procedure for dealing with missing firefighters and the fact that fire brigade officers are not selected, trained and drilled to ensure that they can actually tilt the balance by acting as a “technical fire fighting manager” particularly in such situations.
According to the investigative committee, increased investments must be made in fire fighting knowledge and expertise and in the modification of existing procedures, study materials, and training as well as relevant related exercises.