Chapter 71: Training

¶71.1 In the Phase 1 report, the chairman found various shortcomings in the LFB's training, which were revealed in its response to the fire, both on the fire ground and in the control room.¹⁸⁶¹⁸⁶ Phase 1 Report Volume IV, pages 589-590, paragraphs 27.16-27.20. In this phase of the Inquiry, therefore, we have examined the way in which the LFB identified training needs (particularly those arising from incidents), its approach to the procurement and provision of training and its systems for monitoring the effectiveness of training.

The dynamic and intelligent operational training process

¶71.2 The LFB had a complex system for identifying the need for training and delivering training to staff at various levels. A process known as the dynamic and intelligent operational training (DIOT) process was central to the operation of that system. Its purpose, as described in Policy No. 825 (PN825), was to monitor operational, health and safety and training performance, to identify trends and provide mechanisms to support the maintenance of competence on the part of operational staff.¹⁸⁷¹⁸⁷ {LFB00012695/2} page 2, paragraph 1.5. As Deputy Commissioner Dexter agreed, that somewhat complex description could fairly be summarised as learning from mistakes made in fighting fires and promoting good practice.¹⁸⁸¹⁸⁸ Dexter {Day178/69:21}-{Day178/70:3}. Its principal purpose, and that of the co-ordination board more generally, was to identify risks to operational staff and to provide appropriate training.¹⁸⁹¹⁸⁹ {LFB00055171/2} page 2, paragraphs 1.2 and 1.5; Dexter {Day178/75:17}-{Day178/76:3}. The process could also, in theory, result in the amendment of an existing policy or the introduction of a new policy, but PN825 described that outcome as rare.¹⁹⁰¹⁹⁰ {LFB00055171/8} page 8, paragraph 3.41. Ensuring that the objectives of the process were achieved was the main responsibility of the co-ordination board.¹⁹¹¹⁹¹ Dexter {Day178/69:1-5}.

¶71.3 Central to the process were the arrangements for monitoring incidents and the creation of the associated database described in PN825. The database was used to record comments on the performance of operational personnel or the brigade as a whole during incidents and training.¹⁹²¹⁹² {LFB00055171/4} page 4, paragraphs 3.1-3.2. Such comments, often referred to as "development points",¹⁹³¹⁹³ Cohen-Hatton{LFB00110660/16} page 16, paragraph 58. typically emerged from meetings held after operational incidents or training exercises specifically to consider the quality of the response and the performance of the incident commanders.¹⁹⁴¹⁹⁴ Dexter {Day178/78:5}-{Day178/79:12}. PN825 made it clear that entries should be made on the database only in cases where the performance of an individual, team, piece of equipment or the organisation as a whole had fallen below the required standard or had exceeded expectations.¹⁹⁵¹⁹⁵ {LFB00055171/4} page 4, paragraph 3.3.

¶71.4 Except in the case of monitoring officers, who were required to post comments on the database in certain cases, firefighters of all ranks could post comments if they wished to draw attention to something they considered to be of importance in relation to the operational response. (Comments made as a result of meetings to consider the performance of incident commanders were posted on the database in all cases.)

¶71.5 The Incident Management Policy group, which was part of the Operational Assurance directorate, was responsible for analysing the database and producing six-monthly reports to the co-ordination board identifying significant trends and matters that required attention.¹⁹⁶¹⁹⁶ Dexter {Day178/105:25}-{Day178/106:3}. "IMPD report" refers to the six-monthly reports presented to the co- ordination board. "IMP report" refers to the individual reports produced following meetings to review operational responses and incident command. which provided material for the database.

¶71.6 Although the system could be used by firefighters of all ranks, DC Dexter and Commissioner Cotton agreed that few firefighters made use of the opportunity to make comments.¹⁹⁷¹⁹⁷ Dexter {Day178/82:20-24}; Cotton {Day208/38:9-12}. One biannual incident monitoring report in 2014 shows that entries were made in respect of only 4% of the 47,105 incidents recorded¹⁹⁸¹⁹⁸ {LFB00067840/5-6}. and it follows that 96% of incidents during that period generated no comments at all. The report indicated that those figures represented an increase on previous quarters, when the use of the system must have been even lower.

¶71.7 Commissioner Cotton and Dr Sabrina Cohen-Hatton, head of the Operational Review Team in June 2017, said that operational staff, especially incident commanders, saw development points as negative.¹⁹⁹¹⁹⁹ Cotton {Day208/40:12}-{Day208/41:16}; Cohen-Hatton {Day184/205:14-22}. Ms Cotton also said that both firefighters and officers found it difficult to accept criticism of their operational performance²⁰⁰²⁰⁰ Cotton {Day208/40:21}-{Day208/41:6}. and Deputy Commissioner Dexter said that some staff had voiced fears that they might get into trouble if they admitted having done something wrong.²⁰¹²⁰¹ Dexter {Day178/82:20}-{Day178/83:7}.

¶71.8 Commissioner Cotton said that she saw no connection between the negative perception of development points and the less than enthusiastic use of the system.²⁰²²⁰² Cotton {Day208/41:17}-{Day208/43:23}. On the other hand, Deputy Commissioner Dexter told us that the negative perception of development points was the main reason given for not posting comments.²⁰³²⁰³ Dexter {Day178/91:8-25}. That is the most plausible explanation we were given for the significant under-use of the system. The LFB did attempt to improve the use of the database by seeking to reassure staff that development points were not intended to be punitive and by informing officers of the importance of posting comments, but its efforts were unsuccessful.²⁰⁴²⁰⁴ Dexter {Day178/83:8-25}; Cotton {Day208/44:2}-{Day208/45:10}.

¶71.9 The low use made of the monitoring process and the very low proportion of incidents which gave rise to development points (even allowing for the fact that many of them were very minor) meant that the database was very narrow and could provide the co‑ordination board with only a limited picture of operational trends or training needs. The process concentrated too much on identifying long-term trends, with the result that a serious problem disclosed by a single significant incident could be missed.²⁰⁵²⁰⁵ Spooner {MET00078859/4} page 4, paragraph 4. For example, the database entry for the Shepherd's Court fire in 2016, a significant incident involving the spread of fire across the combustible facade panels of a high-rise residential block and a partial evacuation, failed to identify the spread of fire across external walls or the use of combustible panels as matters to be considered.²⁰⁶²⁰⁶ {LFB00120998}.

¶71.10 Deputy Commissioner Dexter accepted that the incident monitoring process fundamentally relied on the willingness of individual officers on the ground to provide information and that, in the context of a falling number of incidents, the amount of information available to it was steadily diminishing.²⁰⁷²⁰⁷ Dexter {Day178/165:6}-{Day178/166:6}.

Operational News

¶71.11 On receipt of a six-monthly database report, the co-ordination board considered whether any training was required in response to what it disclosed. Training was delivered primarily in the form of articles published in Operational News, the LFB's internal information circular, some of which were accompanied by computer-based training packages. Indeed, Operational News and its associated training packages were the main focus of the co‑ordination board's work.²⁰⁸²⁰⁸ Groves {Day177/29:3-4}; Dexter {Day178/72:10-15}. Commissioner Cotton estimated that only half to two thirds of the operational trends identified in the database reports were in fact chosen as subjects for articles in Operational News.²⁰⁹²⁰⁹ Cotton {Day208/55:2-11}.

¶71.12 The Incident Management Policy group was responsible for producing articles for publication in Operational News, although the articles themselves were drafted by experts from the relevant departments before being reviewed and approved by Operational Assurance.²¹⁰²¹⁰ Dexter {Day178/111:9-16}; Cotton {Day208/61:17}-{Day208/62:9}. They typically took the form of a summary of an existing policy, drawing firefighters' attention to its contents. Babcock produced reports every six months, in conjunction with the Human Resources and Development department, telling the co‑ordination board how the training it was providing had been, or was being, improved to support the topics covered in the previous edition of Operational News. In many of those reports Babcock simply stated that the topics in question were already adequately covered.²¹¹²¹¹ {LFB00036796/4} for example, in relation to Fire Survival Guidance policy.

Station-based training

¶71.13 Commissioner Cotton said that summarising an existing policy in Operational News did not amount to training but had been intended to raise awareness and provide personnel with links to the associated training delivered through fire stations.²¹²²¹² Cotton {Day208/72:3}-{Day208/73:2}. Initial training was provided to firefighters by Babcock, but the subsequent development and maintenance of operational skills was mainly carried out at station level in accordance with the Policy No. 427 (PN427) by means of computer-based training packages and lectures delivered by watch managers, attendance at which was recorded on crews' training records.²¹³²¹³ {LFB00032798/2} page 2.

¶71.14 Watch managers were not provided with any centralised training materials for their lectures (apart from the policies themselves); instead, it was the responsibility of each watch manager to develop their own lectures and deliver them to crews.²¹⁴²¹⁴ Cotton {Day208/73:21}-{Day208/75:7}. For at least five years preceding the Grenfell Tower fire watch managers were given no guidance on how to deliver training and there was no process to ensure that officers who provided training were competent to do so.²¹⁵²¹⁵ Cotton {Day208/77:25}-{Day208/79:5}; Groves {Day177/100:18-22}. Station-based training was monitored by Training Review Information Officers, who were responsible for ensuring that training was provided and that training records were complete and accurate.²¹⁶²¹⁶ Groves {Day177/88:25}-{Day177/89:15}. But we have seen no evidence that any assessment of the quality of station-based training was carried out by those officers or anyone else.

¶71.15 This station-based training was separate from the centralised training that was commissioned by the Human Resources and Development department (later known as the Training and Development department) and provided by Babcock. For ease of reference and consistency, we shall refer to the department simply as "the Training department". The Training department made no contribution to the substance of station-based training and played no part in ensuring that adequate station-based training was provided.²¹⁷²¹⁷ Groves {Day177/94:22}-{Day177/95:5}. Nor did the Training department have any process by which to ensure that station-based training was consistent with the training provided by Babcock, which the LFB's Head of Training, Peter Groves, accepted created an obvious risk of injury.²¹⁸²¹⁸ Groves {Day177/84:11}-{Day177/85:12}. Mr Groves said that responsibility for identifying and assessing any omissions from station-based training lay with the individual borough commanders to whom stations reported, but he accepted that, since 2012, borough commanders had not been trained in how to make such assessments.²¹⁹²¹⁹ Groves {Day177/94:17}-{Day177/96:15}.

¶71.16 The Training department's limited involvement in supporting, monitoring or assessing the quality of station-based training is surprising and difficult to justify. The importance of Operational News to the delivery of training meant that the LFB was heavily reliant on local crews, local station managers and particularly local watch managers for creating and providing the associated lectures. That clearly created a significant risk that the training that crews at different stations received differed in content and quality.

Effectiveness of the system

¶71.17 Commissioner Cotton accepted that articles in Operational News could never provide more than a high-level, cursory exploration of an operational topic.²²⁰²²⁰ Cotton {Day208/80:25}-{Day208/81:3}. She also agreed that the quality of station-based training depended entirely on the skills of individual watch managers.²²¹²²¹ Cotton {Day208/82:4-16}. The co-ordination board's principal method of evaluating the effectiveness of that training was to see whether a particular problem featured in later incident monitoring reports.²²²²²² Dexter {Day178/149:25}-{Day178/151:15} Many of the reports considered by the co-ordination board indicated that it was difficult to teach some lessons, as evidenced by the fact that some problems kept recurring.²²³²²³ Dexter {Day178/157:6}-{Day178/158:19}. Although the reports occasionally noted improvements resulting from certain steps that had been taken (presumably because the number of development points relating to that topic had reduced), there was no system by which the co-ordination board could assess the effectiveness of articles published in Operational News or station-based training.²²⁴²²⁴ Dexter {Day178/152:3-13}. The co-ordination board's approach, which lacked any active assessment of the effectiveness of its training interventions, was wholly inadequate. It was foreseeable that it might fail to identify or resolve significant problems and in any event could identify problems only after they had occurred with sufficient frequency or severity to be noted in one or more incident monitoring reports.

¶71.18 At a meeting held on 14 October 2013, the co-ordination board decided to carry out a fundamental review of the system, because it realised that the same shortcomings were repeatedly occurring. The review was to examine whether the right tools were available to the brigade for monitoring the effectiveness of training and what systems were used by other organisations. It was envisaged that it might lead to a review of the way in which the LFB responded to incidents. Ms Cotton, then AC Operational Assurance, was asked to lead the review.²²⁵²²⁵ {LFB00067818/2}. In the event, however, it was not as fundamental or far-reaching as had originally been intended or as was required, and although it led to a number of recommendations, it did not result in any significant changes to the system for monitoring the effectiveness of training.²²⁶²²⁶ {LFB00123806}. No one was able to explain why the stated aim of the review had not been met or why the opportunity to reform the existing arrangements had not been seized.²²⁷²²⁷ {LFB00040719/2}; Cotton {Day208/88:10}-{Day208/90:9}.

Centralised training courses

¶71.19 In April 2012, the LFB engaged Babcock to provide centralised training to operational firefighters but retained responsibility for training non-operational officers, including the control room and the Fire Safety department. Shortly after being appointed as training provider, Babcock agreed to undertake a review of all the LFB's training courses within the first three years of the contract. The LFB's course review board, chaired by Director Reason, was responsible for considering and approving Babcock's proposals.²²⁸²²⁸ Reason {Day180/100:12}-{Day180/103:22}.

¶71.20 Although Babcock was responsible for creating and providing operational training packages, the LFB alone determined learning objectives and in practice provided much, if not all, of the expertise necessary for the production of the content. At all times it retained ultimate responsibility for training its staff and no training package could be provided by Babcock unless it had been approved by the LFB.²²⁹²²⁹ Groves {Day177/12:14-20}; {Day177/52:6-11}. The systems and structures relating to the training provided by Babcock were entirely separate from those relating to station-based training.

¶71.21 Responsibility for managing the LFB's relationship with Babcock lay with the Training department. The Training department had no role in identifying training needs, recommending new training or requesting changes to existing training. Those were the responsibility of other departments, known as "commissioning departments". The Training department's role was essentially administrative: it collated training needs and requirements received from other departments and organised the process by which they were ultimately translated into training by Babcock.²³⁰²³⁰ Groves {Day177/14:7}-{Day177/15:3}.

¶71.22 The Training department had two teams. The Learning and Development Strategy team was responsible for managing the development of training packages and communicating with Babcock and the commissioning departments.²³¹²³¹ Groves {Day177/8:16}-{Day177/9:7}. The Training Assurance and Business Relationship team was responsible for ensuring that Babcock provided the training that had been agreed and that it met the LFB's learning and training objectives.²³²²³² Groves {Day177/8:3-13}.

¶71.23 Training was commissioned in accordance with a process known as the "training commissioning and alterations process" (TCAP). When a training requirement had been identified, the commissioning department completed a form identifying in broad terms what was needed.²³³²³³ Groves {Day177/20:12}-{Day177/21:4}. Project managers in the Training and Professional Development team, in consultation with the commissioning department, then completed what was known as a "TCAP form" which built on the basic information provided in the training request by addressing practical aspects of both substance and implementation.²³⁴²³⁴ Groves {Day177/21:8-19}. When the team was satisfied that it was correct, the form was submitted to a group consisting of representatives of both Babcock and the LFB's Training department to check that the training would not have a detrimental effect on operational services.²³⁵²³⁵ Groves {Day177/22:20}-{Day177/23:22}. Babcock could suggest additions or changes to training but did so only once in the period before the Grenfell Tower fire.²³⁶²³⁶ Groves {Day177/35:8-23}; Groves {MET00071103/11}.

¶71.24 The next stage of the process was the development of the substantive training. Babcock proposed and designed the content of the training package to meet the identified learning objectives, subject to the approval of the commissioning department.²³⁷²³⁷ Groves {LFB00102138/29} page 29, paragraph 49. Although it managed the commissioning process, the Training department did not play a part in designing the training itself.²³⁸²³⁸ Groves {Day177/45:3-14}. Babcock usually produced three options for providing the training for consideration by the LFB, which then made a choice.²³⁹²³⁹ Groves {LFB00102138/22} page 22, paragraph 32.

¶71.25 When the training materials had been assembled, a pilot training course was developed (except for some computer-based training), which was attended by experts and representatives of the commissioning department to ensure that it met the LFB's needs.²⁴⁰²⁴⁰ Groves {LFB00102138/23} page 23, paragraph 33; Groves {Day177/65:25}-{Day177/66:11}. If the pilot course was considered satisfactory, it was necessary to obtain the commissioning department's approval, confirmation from Babcock that the design was complete and approval from the Head of Fire Stations and the Training department for the provision of the training to operational staff.²⁴¹²⁴¹ Groves {Day177/65:12-24}; {Day177/67:18-25}. At that point the training could be rolled out. Some training packages were either delayed or not released at all following the completion of a TCAP form.

¶71.26 A consistent theme of the evidence was that Babcock lacked the expertise required to develop appropriate training. 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.²⁴²²⁴² Graham Ellis {LFB00118230/15} page 15, paragraph 69; Reason {Day181/30:16-23}. The problem was most acute at the start of the contract in 2012, particularly in relation to incident command training. It was therefore forced to rely on LFB officers to provide the necessary expertise, with the result that it was not always possible to implement much-needed changes to incident command training with sufficient urgency.²⁴³²⁴³ Groves {Day177/47:16}-{Day177/48:9}; {Day177/48:20-25}. Babcock's reliance on the LFB for expertise also delayed other areas of training, including training on the use of breathing apparatus and real fire training.²⁴⁴²⁴⁴ Groves {Day177/55:2-19}.

¶71.27 Although Mr Groves considered that it was Babcock's responsibility to secure the expertise it needed, he rightly accepted that, whatever its contractual arrangements with Babcock, the LFB ultimately remained responsible for ensuring that firefighters were adequately trained.²⁴⁵²⁴⁵ Groves {Day177/52:6-11}.

¶71.28 A report by Ribband Starr Ltd, commissioned by the LFB after the Grenfell Tower fire, found that many within the LFB regarded the commissioning process as cumbersome and capable of causing significant delay in the design and delivery of new courses.²⁴⁶²⁴⁶ {LFB00067786/33}. All the LFB witnesses who gave evidence about training were of that view.²⁴⁷²⁴⁷ Groves {Day177/56:17}-{Day177/57:5}; Reason {Day180/106:10-22}; Cotton {Day208/65:7-8} and Dexter {Day178/125:6-8}. We agree with their assessment.

¶71.29 We were told that all training courses referred to in the annual statement of training requirements produced by the Training department were audited separately at least once a year by the LFB and Babcock and that the results were discussed at monthly meetings between Babcock and the Training department to decide whether any change to a particular training course was needed.²⁴⁸²⁴⁸ {LFB00055127/23} page 23, paragraph 7.1; Groves {Day177/68:15}-{Day177/69:23}. The Inquiry has not seen any evidence of audits or discussion of their findings. In particular, there is no evidence that audits resulted in the creation or amendment of any training packages. If audits were carried out, they appear to have had no effect on the content of training.

¶71.30 PN825 refers to four levels of evaluation used by the LFB to assess the effectiveness of training. Level 1 involves the use of questionnaires seeking the opinions of those who have attended courses,²⁴⁹²⁴⁹ Groves {Day177/70:2}-{Day177/71:8}. Level 2 gauges what trainees have learnt, Level 3 assesses whether trainees have been able to apply their new skills and knowledge to the workplace, and Level 4 considers the effect of the training on the organisation as a whole.²⁵⁰²⁵⁰ {LFB00055171/13} page 13, paragraph 6.10. We were told that training courses, apart from computer-based training, had been subject to Level 1 evaluation but that no formal Level 3 or Level 4 evaluations had been carried out.²⁵¹²⁵¹ Groves {Day177/71:21}-{Day177/73:7}.

¶71.31 There was no system in place for evaluating the performance of staff who had attended training courses by reference to previously agreed criteria. Once a training package had been developed by Babcock and approved by the commissioning department it was assumed to be suitable.²⁵²²⁵² Groves {Day177/74:16-25}. That might have been a reasonable approach if the LFB had implemented adequate arrangements to review the effectiveness of training courses, but it is plain that it had made no such arrangements. The approach was particularly unsound in circumstances where there was no process at all by which the Training department was able to review the overall effectiveness of a training programme.²⁵³²⁵³ Groves {Day 177/82:8-12}.

¶71.32 We have been left with the clear impression that, instead of adopting a system which measured the effectiveness of training by reference to previously agreed criteria, the LFB simply waited 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 obvious weaknesses of that approach were aggravated by the fact that, as the number of incidents declined, progressively less confidence could be placed in a system that relied on problems being identified at incidents.²⁵⁴²⁵⁴ McGuirk, Firefighting Expert Report {SMC00000046/47-50} pages 47-50, paragraphs 123-126.

Conclusions

¶71.33 The procedure adopted by the LFB for commissioning training in the years leading up to the Grenfell Tower fire placed much emphasis on ensuring that the right courses were produced and that training did not interfere with operational requirements. Both were laudable aims. However, the process was very cumbersome and inevitably led to excessive delay in providing new courses. There was also a disturbing absence of any system for evaluating the effectiveness of courses once they had been introduced. At a local level too much responsibility was placed on watch managers to devise and deliver training, with insufficient support and oversight. Since the quality of training at that level depended to a considerable extent on the skills of individual watch managers, the quality was bound to be variable.

¶71.34 In the Phase 1 report the chairman found that the incident commanders who were present during the early stages of the fire had not received sufficient training to enable them to understand the nature of the fire that confronted them and how it was likely to develop. We do not think that the deficiencies in the system for commissioning training or the arrangements for delivering training at station level that we have identified were responsible for that shortcoming, although we cannot be confident that, if there had been sufficient understanding of the need for training in the risks of cladding fires in high-rise buildings, it would have been delivered promptly and effectively. In the next chapter we examine why the LFB failed to ensure that those who acted as incident commanders were properly trained for the task.