The HSE has served two improvement notices on the London Fire and Civil Defence Authority alleging firefighters in the capital have been inadequately trained and safety poorly monitored.
The authority, which runs the 6,800-strong London Fire Brigade, has been told to reform training to ensure that there is no repetition of the incident in which two firefighters, Terry Hunt and David Stokoe, died.
It is highly unusual for the HSE, the Government-funded safety enforcement agency, to take action against a fire brigade. Mr Hunt, 33, from Chadwell Heath, Essex, and Mr Stokoe, 25, from Hornchurch, Essex, died after running out of breathing apparatus oxygen while fighting a warehouse fire in south-east London in July 1991.
The fire at Hays Business Services in Bromley was started by arsonists and an inquest jury subsequently returned verdicts of unlawful killing on the two firefighters.
The serving of the notices is revealed in a report sent to all 114 fire stations by Brian Robinson, Chief Fire Officer and director of operations for London.
An appendix to the report outlines several errors. When firefighters withdrew to get a larger hose they left a hosereel which prevented fire doors from closing, intensified the flames and allowed smoke to spread.
However, the most serious mistakes occurred after Mr Hunt and Mr Stokoe teamed up with two men from another station, one of them a station officer, to lay a guideline through the smoke to the source of the fire.
As they did this a second branch guideline was, unknown to them, being laid by another team. Both lines were left lying on the floor instead of being tied to nearby objects as they should have been.
When the first team returned they faced two possible routes out and the station officer decided which way to go. Mr Robinson's report says that the personal line connecting Mr Stokoe to the firefighter from the other station 'was forcibly broken'. It does not go into further detail.
However, one source said yesterday that a fierce argument broke out between the station officer, from Stratford station, and Mr Hunt and Mr Stokoe, from Silvertown. This was overheard on the radio by officers outside and culminated in the Stratford men going one way to safety and the Silvertown firefighters taking the other route. Nobody was told of the split at this stage and Mr Hunt and Mr Stokoe got lost and died.
The fire authority said: 'There was no criticism of our recruit training but, in the view of the HSE, continuing or refresher training was in some instances not up to standard.
'We have set up a permament specialist team which goes round to monitor training at all fire stations and which is ensuring that everything which should be done is being done.'
The HSE said that when the review was completed in London the lessons learned would be applied to other British fire brigades.