'A chronic lack of effective leadership, combined with an undue emphasis on process and a culture of complacency' - what the Grenfell Tower Inquiry said about the London Fire Brigade
Why and how did the LFB fail to learn the lessons of the Lakanal House fire during the eight years before Grenfell? The inquiry report digs into the detail and blames culture and management
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Over the last few months, I have provided summaries of the Grenfell Tower Inquiry’s findings on various parties involved in the failures which led to the disaster.
Today it is time to turn to the London Fire Brigade. While a much-loved institution with obvious bravery and public service at its heart, there is no value in obscuring the contribution the LFB’s failures made to the Grenfell Tower disaster.
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In short - many of the victims could have escaped and lived if operation had been different, and had not relied on ‘stay put’ for so long after the building had obviously failed to contain the fire.
What makes this particularly shocking is that the LFB had already made these mistakes. In July 2009 six people died in a fire at Lakanal House, south London. As well as being a major missed opportunity by central government, this fire was a “watershed” moment for the LFB which “prefigured in many respects” events at Grenfell Tower eight years later.
But the lessons from this fire were not learned and instead the mistakes were repeated. The lion’s share of the report’s pages on the LFB are dedicated to explaining why.
‘Senior officers failed to provide the energetic and effective response that was required’ - the early response to Lakanal House
Shortly after the Lakanal House fire, the LFB set up a “Lakanal House Board” to establish immediate changes it needed to make before the coroner’s inquest began in 2013, steps which became known as “pre-inquest actions”.
But these steps were deficient. In particular, the report said, they “failed to include any response to what should have been the principal concerns arising from the Lakanal House fire… the widespread failure of compartmentation and the spread of fire across external walls due to the use of combustible construction materials.”
And even with this major gap, the steps were not fully implemented. A review in January 2013 was unable to confirm whether or not 29 of the 34 recommendations had been implemented.
But this didn’t raise any concerns - the report said that “neither [then assistant commissioner Dany] Cotton [who was responsible for training] nor anyone else appears to have considered whether the implementation of the Lakanal pre-inquest actions had been effective”.
After the coroner’s inquest in 2013, the board overseeing the implementation of these recommendations was disbanded, leaving the LFB “with no means of ascertaining whether the outstanding pre-inquest actions had been completed”.
The report called this process a “significant failure… which prevented [the LFB] from responding more effectively to the fire at Grenfell Tower”. “Senior officers failed to provide the energetic and effective response that was required to an incident of such significance, for which [then] Commissioner [Ron] Dobson must bear primary responsibility,” it said.
‘That view was both wrong and short-sighted’ - the failure to warn operational teams about the risk from combustible external panels
These internal recommendations for change were before the coroner’s inquest.
But after the inquest, the coroner made various recommendations to the London Fire Brigade in her ‘prevention of future death’ report, many of which would prove to be extremely pertinent to the failures at Grenfell Tower.
A working group was set up to oversee these changes by the body at the Greater London Authority which oversees the work of the LFB.
This group met six times through to July 2014, at which point a report was submitted by senior LFB officers which said the group had fulfilled its purpose and should be wound up.
“That recommendation was accepted and the working group was formally closed,” the inquiry report said. “However, the [LFB’s] report failed to disclose that a number of important items remained outstanding and the closure of the working group gave the misleading impression that all the proposed changes had been made.”
“The LFB denied members of the working group the opportunity to challenge the Commissioner [Ron Dobson] about the LFB’s dilatory and incomplete progress and, more broadly, prevented them exercising their public duty of holding the LFB to account,” the report said.
One thing that was done after the Lakanal House fire was the creation of a ‘Lakanal House Case Study’ - a computer-based training programme for station staff and a half-day seminar for those at the rank of station manager and above.
But this ‘case study’ was partial - it did nothing to inform staff about how to recognise when compartmentation in a building had been lost, the risks of external combustible panels or how to handle calls from residents trapped in buildings experiencing these fires.
The inquiry panel said that this case study “fell far short of what was required” and “failed to address the most important aspects of the Lakanal House fire”.
This was particularly concerning, because the organisation as a whole - particularly senior officers and those in its specialist fire safety team - were well aware of the potentially widespread risk of fire spread over combustible materials, having penned a letter to government warning of this risk as early as 2009.
It had received further warnings - such as a fire in Kingston in 2010 which spread rapidly over plastic drainpipes. This was followed by extensive communication with government about the risks of external fire spread and the need to make changes to building regulations.
There were also fires overseas, industry conferences attended by senior LFB officers where the risks were raised and further fires in London - including the major Shepherd’s Court blaze in 2016.
But its knowledge of these risks - held by senior officers and its specialist fire safety and enforcement teams - was never communicated to its front line, who would ultimately have to fight the fires.
“That reflected both a failure of organisation and management and a failure on the part of individual officers to display the breadth of vision to be expected of them,” the report said.
‘A wasted opportunity and not fit for purpose’ - the failure to develop guidance on reversing stay put
After the Lakanal House both national and London-specific policies for fighting fires in high rise buildings were updated - with the intention that they take account of the lessons from the fire.
The LFB was appointed by the Home Office to lead the redrafting of the national guidance - known as GRA 3.2.
Central government had been specifically told by the coroner to ensure this guidance was updated to reflect the need to reverse the stay put policy and evacuate a building if a fire got out of control.
But the revisions put forward by the LFB’s team did not address this. This discrepancy was raised by civil servants, who ultimately crowbarred wording on this point into the document on the last redraft, with little detail or policy thought given about how to implement it.
“Within [government] the document was described by some as a wasted opportunity and ‘not fit for purpose’,” the inquiry report said.
The LFB then updated its local policies to take account of the changes to the national policy.
This meant it should have changed its policies to reflect the new national guidance, which it had led the redraft of.
But its new guidance did not include the new national requirement to have contingency plans to evacuate buildings if a stay put policy became untenable.
“The stark conclusion is that [the LFB guidance] did not properly reflect the requirements of GRA 3.2 in that respect,” the inquiry report said.
The inquiry report said this was “possibly because those at the LFB responsible for it did not think that the LFB needed such detailed advice and guidance or possibly because they did not attach sufficient importance to it”.
“Regrettably, however, that message was not properly absorbed by senior managers, and as a result operational firefighters were not properly prepared to deal with another major failure of compartmentation when it eventually occurred at Grenfell Tower,” it added.
‘The [training] process was very cumbersome and inevitably led to excessive delay’ - the general failure to update training in response to incidents
As well as a failure to warn its front line about the risk of a cladding fire, a general failure to provide appropriate, up-to-date training was flagged in the report.
The LFB sought to use evidence from prior incidents to identify the need for new training, and as such maintained a database which allowed firefighters of all ranks to add comments about learning points from incidents.
These were then reviewed by a board, which could result in amendments to policy and training updates.
The trouble was very few comments were ever actually logged. Just 4% of 47,105 incidents attended in 2014 attracted a comment of any sort, the report said. Adding comments was seen as an admission of failure, with staff finding it “difficult to accept criticism” and fearing “they might get into trouble”.
Significant incidents, like the Shepherd’s Court fire in 2016, led to no comments being added to the system - despite the obvious evidence it posed about the need to at least partially evacuate buildings if fire spread externally.
A lot of the training was carried out at station level, using computer-based packages produced by Babcock (a private consultancy which had won the contract to provide training) or lectures from watch managers.
But these managers had no materials for these sessions, and had not been trained in how to deliver them for five years before Grenfell. “There was no process to ensure that officers who provided training were competent to do so,” the report said.
On top of this, Babcock was also providing centralised training to firefighters - mainly at its centre in east London. But this proved an odd contradiction: Babcock didn’t know how to train firefighters and had to ask the LFB for advice.
“A consistent theme of the evidence was that Babcock lacked the expertise required to develop appropriate training,” the report said. “As a result, the LFB frequently had to provide experts from within its own ranks to assist it, which was a significant drain on resources.”
The LFB also had no means to assess the quality of its training, instead, in the words of the report, it was “simply waiting to see what, if any, problems subsequently arose at incidents”.
“Such an approach might or might not reveal any deficiencies in training, but if it did, it was by then likely to be too late,” the report said.
Specific training for incident commanders - including on how and when to revoke the stay put policy - which was specifically required by the Lakanal House coroner fell into this blackhole.
Babcock wrote a report which recommended 16 exercises which could be introduced to implement the Lakanal House coroner’s findings on this point.
But the LFB told the Greater London Authority panel scrutinising its work that Babcock had said the coroner’s recommendations were covered by existing training. The inquiry report called “misleading”.
The 16 changes initially identified by Babcock ultimately became just one exercise. In the end, this was only rolled out to one grade of incident commander in August 2016 - meaning many received no fresh training at all.
The report placed responsibility for this failure with senior officers, including Ms Cotton (who came commissioner in January 2017) and her predecessor Mr Dobson, who said he believed the coroner’s recommendations were already addressed by existing training. “Views of that kind… are likely to have undermined the importance attached to the training packages and to have added to the delay,” the report said.
‘There was a chronic, systemic failure’ - training call handlers
As well as operational firefighters, staff in the LFB’s control room who handled 999 calls also needed to learn lessons from the Lakanal House fire.
There, as at Grenfell Tower, victims had been told to stay put when it was no longer safe to do so, had lost the chance to escape when it would have been possible and died as a result.
But here, too, opportunities to change were missed.
A “gap analysis” carried out in 2010 as a response to Lakanal, compared national guidance on calls from those trapped in burning buildings to the LFB’s own policies, in order to identify any deficiencies.
A particularly pivotal gap was that the national guidance cautioned against being too quick to offer reassurance, in case it may lull callers into a false sense of security about their chance of being rescued. But the LFB’s own policies were weak in this area - it actively encouraged call handlers to use reassuring phrases and build an emotional connection. This was part of what had gone wrong at Lakanal.
But despite this obvious gap, the analysis was silent on this point. The LFB’s policy remained unchanged.
“The failure to amend [LFB policy] was significant,” the report said. “[During the Grenfell Tower fire, call handlers] invariably told callers that firefighters were on their way without having a sound basis for doing so.As a result, some callers were lulled into a false sense of security, remained in their flats and did not attempt to leave, despite the fact that escape was possible.”
There was also criticism of a failure to develop a clear policy for an incident where a large number of calls from people trapped inside a burning building were received at once - despite a fairly lengthy series of incidents which flagged that this was a possibility and a weakness.
“Regrettably, we have come to the conclusion that despite all the indications that a large number of calls seeking fire survival guidance could be generated by a single incident… the LFB failed to recognise that possibility and therefore failed to take any steps to prepare for it,” the report said, adding that at Grenfell Tower its teams were forced to adopt “improvised methods” to fill this gap.
“That represents a major failing on the part of the LFB,” the report said.
As well as the development of policies on training, there was also the question of delivering the training itself.
The report said that “none of [the senior staff responsible for this] exercised very much oversight of” training call handlers, with the responsible assistant commissioners delegating it down to a principal operations manager who himself took “a laissez-faire style of management under which he did not expect to receive reports… unless there was a problem”.
“In our view, such a detached approach to training should never have been allowed,” the panel said.
In 2010, staff were given a full day’s training, which included active role play - as part of the LFB’s response to the failures at Lakanal.
But the inquiry report said this training was “flawed” and “outdated”, with no reference to the rapid external fire spread which had taken place at Lakanal House. This was called “a serious oversight”, which senior staff were “unable to explain”.
Worryingly, the training also continued to advise callers to offer reassurance and form an emotional bond with the caller - behaviour by this point deemed bad practice by the national guidance.
These (and other) flaws were actually picked up by a station manager who reviewed the training package, but were not acted upon.
According to national guidance, call handlers should have received full refresher training from a fire safety at least once annually, but the LFB watered this down to a classroom-based session every two years, and individual computer-based training in the other years.
Even this was not fully implemented. The computer package took a long time to develop, with staff instead told to learn independently from written resources in their breaks. The in-person training was reduced from a full day to four hours. The active role play was removed from the classroom training - due to staff feeling “embarrassed” when taking part.
And from 2012, senior officers decided to stop using specialist ‘fire safety officers’ to deliver the training, because it was “an unnecessary use of resources”, instead allowing the control room staff to train each other. This went against national guidance, and the LFB’s own post-Lakanal plan.
Despite all this, in January 2013, the LFB told the Lakanal House coroner that control room staff were receiving regular refresher training which involved active role play, which was not true. The report said that “no satisfactory explanation was given for this failure”.
Even in its watered down stage, staff training was sporadic. The computer training package was still beset by technical difficulties and was not fully available. The in-person sessions were limited due to a lack of resource.
Figures showed that in 2013 and 2014, only 28% and 29% respectively of control room staff received any form of training on fire survival guidance, and in 2015, no such training was carried out at all because of broader problems with a botched IT roll out within the LFB.
Although some senior staff said these figures were not reliable, the inquiry panel nonetheless concluded that “there was a chronic, systemic failure to ensure that effective fire survival guidance refresher training was consistently provided”.
On top of this, the senior officers responsible did not tell the board overseeing the response to Lakanal that “training had fallen far short of that which had been approved and promised to the coroner”.
The inquiry report said that none of the senior officers responsible had given the issue “the seriousness or dedication it deserved”, despite the evidence of a “real danger to life” from the Lakanal House blaze.
“There is no justification for such a longstanding failure to address a vital element of the control room’s work and one which touched directly upon public safety,” it said.
‘A serious indictment of an organisation whose principal purpose is to protect the public’ - overall conclusions
Overall, the report concluded that the LFB’s failure did not lie in misunderstanding the significance of what had happened at Lakanal House in 2009. “On the contrary,” it said, “It understood its significance immediately.”
The trouble was its failure to implement the necessary changes. “The evidence clearly shows that the LFB’s failure was attributable to a chronic lack of effective leadership, combined with an undue emphasis on process and a culture of complacency,” the report said, adding that former commissioners Ron Dobson and Dany Cotton bear “ultimate responsibility” for this - although it said this should not “obscure the failures” of other senior officers.
“When a problem arose which called for careful and detailed consideration, on too many occasions the LFB’s response was that change was unnecessary or too difficult,” the report said.
“The tragic conclusion is that the Lakanal House fire forewarned the LFB about the existence of the shortcomings which revealed themselves once more on the night of 14 June 2017.
“Those shortcomings could have been avoided if the LFB had been more effectively led in a number of respects. On any view, that is a serious indictment of an organisation whose principal purpose is to protect the public and of the quality of its leadership.”
This is part of a series of digests on the findings of the Grenfell Tower Inquiry report. Previous posts have covered:
RBKC and the TMO as client and building control
The recommendations and the government’s response to them
I have two more to come, one dealing with the aftermath and another specifically dedicated to fire doors.
This content is not behind a paywall, but since it takes time to create and upload each piece, do please consider becoming a paid subscriber (especially if this project is something that you value, and you have the means to do so), which is either billed monthly at £3.50 or annually at £35. A paid subscriber has full access to the back catalogue of posts.
If you pay £40 or more for an annual subscription, I will send you a signed copy of my book. Or you can buy a copy here.