Chapter 72: Incident command training

¶72.1 It became apparent during the course of the Grenfell Tower fire that few, if any, of those who were called upon to act as incident commanders in the early stages of the fire had received training in how to recognise a fire in the external wall of a high-rise residential building or to understand its likely consequences. Nor had they received any training in the principles of evacuation from high-rise residential buildings when a "stay put" strategy was no longer tenable, in how to decide whether evacuation was necessary or in how to carry it out safely and efficiently.²⁵⁵²⁵⁵ Phase 1 Report Volume IV paragraph 27.16. It was therefore necessary for us to examine the way in which the LFB trained those who might be expected to assume the responsibility of incident commander and in doing so we must assess its response to the recommendations on incident command made by the coroner in March 2013, following the Lakanal House inquests.

The coroner's recommendations

¶72.2 There appears to be little doubt that before the Lakanal House fire in July 2009 only a small number of officers in the LFB were aware of the dangers posed by combustible materials when used in external walls of buildings or could recognise and understand the significance of a fire of the kind that broke out in Grenfell Tower in June 2017. Those who could and did were almost entirely confined to the Fire Safety department and did not include any of those who could be expected to act as incident commanders.

¶72.3 The Lakanal House fire should have changed that for ever, because operational firefighters at many levels witnessed at first hand the effects of fire spreading across an external wall as a result of the presence of combustible panels. They also witnessed the extensive loss of compartmentation caused in part by the spread of fire both externally and internally, the latter as a result of the use of unsuitable materials in the refurbishment of the interior, in particular some of the corridors. That should have been enough to prompt the LFB to take urgent steps to ensure that in future incident commanders were able to recognise a rapid loss of compartmentation and the spread of fire on the exterior of a building, if it occurred, and knew how to respond, almost certainly by evacuating the whole or part of the building. However, the need for such training should have been put beyond doubt by the coroner's rule 43 letter, written over three years after the fire.

¶72.4 In her rule 43 letter to the LFB the coroner recommended that consideration be given to the training of incident commanders to enhance their performance in a number of respects, including their ability to understand and react quickly to changing circumstances and to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle.²⁵⁶²⁵⁶ {LFB00032158/2-3}.

The LFB's response

¶72.5 AC Cotton, who was head of the department responsible for incident command policy and training at the time, was asked to respond to the coroner's recommendations.²⁵⁷²⁵⁷ Reason {Day180/169:1}-{Day180/170:8}; Cotton {Day208/157:10}-{Day208/159:10}; {Day208/160:5}-{Day208/162:7}. Her suggested response, which was ultimately adopted by the Commissioner's Group, was that the LFB should work with Babcock to ensure that all the points raised by the coroner were covered in its current review of incident command training in the period up to 2015 and to create a case study training package which would teach the lessons to be learnt from the Lakanal House fire and other high-rise fires, such as the one at Shirley Towers. The suggestion ultimately resulted in the Lakanal House case study, to which we will refer later. However, as noted there, the case study did not provide adequate training for incident commanders facing a widespread failure of compartmentation of the kind experienced at Lakanal House, nor did it specifically address the coroner's incident command recommendations.²⁵⁸²⁵⁸ {LFB00034062/22}.

¶72.6 The LFB accordingly instructed Babcock to incorporate the coroner's recommendations into its review of incident command training, which by then was already in progress. In addition, the LFB instructed Babcock to conduct a separate review to confirm that all the coroner's recommendations relating to incident command were fully covered by existing training courses.²⁵⁹²⁵⁹ {LFB00067820/13-14}, action 3; {LFB00003716/5}; {LFB00038170}; Reason {Day181/28:7}-{Day181/55:13}. That review was carried out in mid-September 2013 and the results were provided to the Operational Assurance department.²⁶⁰²⁶⁰ {LFB00038170}. The results of Babcock's review were not considered by Director Reason.²⁶¹²⁶¹ Reason {Day181/49:2}-{Day181/50:21}; {Day181/54:14-23}.

¶72.7 Babcock concluded that the existing training explicitly or implicitly covered all the areas identified by the coroner. Some were the subject of both theoretical and practical training; in other cases the extent to which the areas identified by the coroner were covered and the performance of trainees assessed depended on the exercises they undertook. Babcock recommended that the LFB revise its existing exercises in order to implement the coroner's recommendations and identified 16 exercises which could provide starting points for new exercises which would fully implement those recommendations.²⁶²²⁶² {LFB00038170}; {LFB00115289}.

¶72.8 In Chapter 74 we describe how in June 2013 LFEPA had set up a working group to monitor the LFB's response to the Lakanal House fire. The LFB's report to the working group on 30 September 2013 gave a different impression from that indicated by Babcock in its review. It said that Babcock had confirmed that all the coroner's recommendations were covered by the existing training on incident command, although there might be opportunities for emphasising the experience obtained from the Lakanal House fire in some cases.²⁶³²⁶³ {LFB00067820/13-14}. That was inaccurate. Babcock had concluded that further work was required on the existing exercises and had identified the fact that some candidates for incident command might not have taken part in any of the relevant exercises.²⁶⁴²⁶⁴ {LFB00038170}; {LFB00115289}. In such cases they would not have received any training on matters covered by the coroner's recommendations. However, the fact that some incident commanders would not receive training on matters falling within the coroner's recommendations was an important fact that was omitted from the LFB's report.

¶72.9 In the LFB's report to the working group in November 2013 that task was marked as having been completed. For reasons explained below, that too was inaccurate, since the work was by then far from complete.²⁶⁵²⁶⁵ {LFB00067832/24-25}. Director Reason accepted that the reports did not disclose that Babcock had found that some individuals were not receiving training in the areas identified by the coroner, that incident command training therefore required enhancement, and that the work to develop training exercises was continuing.²⁶⁶²⁶⁶ Reason {Day181/84:3-18}. He said that he had relied on the information he had received from the co-ordination board's monitoring of the response to the recommendations and that it had been the responsibility of AC Cotton and her commissioning department to ensure the accuracy of the information.²⁶⁷²⁶⁷ Reason {LFB00067846/13-14} pages 13-14, paragraph 17; Reason {Day181/48:12}-{Day181/50:21}; {Day181/82:11}- {Day181/84:18}. He told us that he had provided the working group with the information that AC Cotton's department had collated for the co-ordination board.²⁶⁸²⁶⁸ Reason {Day180/150:11}-{Day180/151:8}; {Day180/157:1-7}.

¶72.10 AC Cotton considered that the reports were misleading but said that she was puzzled why the tasks had been marked as completed, because at that stage they were very far from completing the enhancement to the training programme that Babcock was going to undertake.²⁶⁹²⁶⁹ Cotton {Day208/224:21}-{Day208/226:12}; {Day208/235:7-25}. She said that she could not recall ever having seen a report to the co‑ordination board indicating that the task had been completed; if she had, she would have challenged it.²⁷⁰²⁷⁰ Cotton {Day209/17:17}-{Day209/21:21}.

¶72.11 AC Cotton disputed Director Reason's evidence that he had depended on reports emanating from the co-ordination board. In her view, he had a far better understanding of the position than his evidence suggested. She thought he had been fully aware that a number of tasks were outstanding because he was a member of the co-ordination board and had seen the progress reports. She said that the reports on incident command training had been discussed at length in directorate management board meetings and in her meetings with him. She added that Director Reason was not the sort of person who would accept what was given to him at face value. He would explore the detail.

¶72.12 In January 2014 Director Reason asked Adrian Bevan, a health and safety manager in the LFB,²⁷¹²⁷¹ Hayward {Day201/30:1-10}. to provide him with a document to support the paragraph in the report to the working group which stated that all seven recommendations were adequately covered by the existing training exercises. Having made some enquiries, Mr Bevan reported that the position was not as clear as had been thought because there had been some confusion between current training exercises and the new exercises that Babcock were developing. At that point, if not before, therefore, Director Reason must have been aware that the position was not as had been reported to the working group. However he did not attempt to correct the reports.²⁷²²⁷² {LFB00094806/2}; {LFB00118750}; Reason {Day181/101:11}-{Day181/109:18}; {Day181/141:14}-{Day181/148:5}. Director Reason should have ensured that his reports to the Lakanal House Working Group accurately reflected the delay to the new incident command training programme.

Additional training

¶72.13 Babcock's initial proposal to revise and refine 16 command training exercises was not carried out. First the number was reduced to six and in the end only one, the Holcroft House exercise, was developed. The reasons for that are not entirely clear.²⁷³²⁷³ {LFB00003716}; Reason {Day181/62:16}-{Day181/75:20}; Cotton {Day209/2:10}-{Day209/3:10}; {Day209/13:11-18}.

¶72.14 The Holcroft House exercise became available in 2016. It centred on a fire at a high-rise residential block in Battersea which was undergoing decorative and remedial building works. The overview of the exercise described it as increasing in complexity to involve persons reported as trapped and needing rescue, fire survival guidance calls, significant fire growth and the need for mass evacuation, compounded by the hazards and risks associated with the remedial building works. It was intended to create significant challenges for crew managers and watch managers. A detailed description of the exercise and its potential variations disclosed that it involved only two fire survival guidance calls (at the Lakanal House fire there had been five) and the spread of fire from the original compartment only to the communal corridor, rather than to other floors. The training guide stated that trainees were expected to consider partial or full evacuation of the block, but there was nothing in the course materials designed to help them understand why they might need to consider an evacuation or how they might organise one.²⁷⁴²⁷⁴ {BAB00000011}; Reason {Day181/110:10}-{Day181/129:21}. For all those reasons, as Director Reason accepted, that particular training package was not an adequate response to the coroner's recommendations.²⁷⁵²⁷⁵ Reason {Day181/128:18}-{Day181/129:21}. Director Reason was not involved in the development of that package but did have ultimate responsibility for changes to the LFB's incident command training in response to the coroner's recommendations until his retirement on 2 January 2015.

¶72.15 There was conflicting evidence about whether it was intended to make the Holcroft House exercise available to all potential incident commanders,²⁷⁶²⁷⁶ {LFB00004801/29}, action 3b; Groves {Day177/123:12}-{Day177/127:13}. but in the event, it was restricted, for reasons which are not clear, to Level 1 incident commanders (crew managers and watch managers), rather than being provided to all four levels of incident commander as had been envisaged by Babcock's initial proposal.²⁷⁷²⁷⁷ {LFB00003716}; {LFB00115289}; Reason {Day181/73:4-22}. As a result, a significant number of incident commanders did not receive the training which had been designed to implement the coroner's recommendations.

¶72.16 Director Reason told us that the LFB was likely to have partially implemented the coroner's recommendations before August 2016 through Babcock's making simple adjustments to existing courses and by changing the procedures for assessing suitability for senior officer positions.²⁷⁸²⁷⁸ Reason {Day181/76:2}-{Day181/77:12}. However, apart from a report which stated that assessments of suitability for incident command covered the challenges of managing incidents affecting high-rise buildings,²⁷⁹²⁷⁹ {LFB00067812/5}. there was no contemporaneous evidence that changes to training courses or to the assessment procedures had been made to reflect the coroner's recommendations. If changes of that kind had been made, we think they would almost certainly have been recorded, if only informally. We are therefore unable to accept what Director Reason said on that matter.

¶72.17 We have no doubt that the LFB intended to incorporate the coroner's seven incident command recommendations into Babcock's review of incident command courses,²⁸⁰²⁸⁰ {LFB00042089}; {LFB00067832/25}; {LFB00003716/8}. which should have ensured that from 2015 the recommendations were reflected in new incident command courses. However, the evidence clearly shows that they were not considered in any detail by either Babcock²⁸¹²⁸¹ {LFB00042089}; {LFB00073973}. or by the LFB during its review of the courses.²⁸²²⁸² {LFB00043552}; Reason {Day181/130:1}-{Day181/138:10}; Cotton {Day209/40:6}-{Day209/47:23}. That was a significant failing by the LFB, which should have ensured that the lessons to be learnt from the Lakanal House fire were at the heart of the review that it had instructed Babcock to undertake.

¶72.18 Director Reason told us that the LFB's Course Review Board and Babcock's review of the training courses were separate from the recommendations of the Lakanal House Board and those made by the coroner.²⁸³²⁸³ Reason {Day180/100:12}-{Day180/103:22}. Although they may have had separate origins, however, it was clear that the LFB intended to incorporate the coroner's recommendations into Babcock's review of training, as indeed had been conveyed to the coroner.²⁸⁴²⁸⁴ {LFB00042089}. That was also confirmed by AC Cotton, who was involved in the review of training courses relating to incident command that was overseen by the Incident Command Project Board.²⁸⁵²⁸⁵ Cotton {Day208/208:3}-{Day208/210:17}; Cohen-Hatton {Day185/69:9-14}. Both AC Cotton and Director Reason could and should have ensured that the incident command recommendations were taken into account in that course review.

¶72.19 Even if the new incident command courses adequately reflected the lessons to be learnt from the Lakanal House fire, most of them had not been made available to operational personnel by the time of the Grenfell Tower fire. Courses for Level 1 incident commanders were made available between 2016 and 2017, but courses for Level 2 (station managers and group managers), Level 3 (Deputy Assistant Commissioners) and Level 4 (Assistant Commissioners and above) were either yet to be made available or were still being worked on at the time of the Grenfell Tower fire.²⁸⁶²⁸⁶ Groves {Day177/140:16}-{Day177/141:18}; Cotton {Day209/73:21}-{Day209/76:23}. That was almost three years after the LFB had received Babcock's report on its review of training courses and over two years after the revisions should have been completed.²⁸⁷²⁸⁷ Groves {Day177/142:11}-{Day177/143:7}; Cotton {Day209/75:22}-{Day209/76:4}. AC Cotton described that rate of progress as "worse than slow". She said that she had regularly reported her frustrations and serious concern about the lack of progress that was being made.²⁸⁸²⁸⁸ Cotton {Day209/76:5}-{Day209/77:15}.

¶72.20 We heard forthright evidence from a number of witnesses about the difficulties that Babcock had experienced in providing incident command training, which they attributed to its lack of expertise (which required a greater contribution from the LFB than had been expected), delay in creating training packages and difficulty translating proposals for training into courses.²⁸⁹²⁸⁹ Ellis {LFB00118230/15} page 15, paragraphs 69-71; Groves {Day177/46:3}-{Day177/55:19}; {Day177/116:7}- {Day177/120:24}; Reason {Day181/30:16-23}; {Day181/70:5}-{Day181/73:3}; Cotton {Day208/205:21}- {Day208/206:3}; {Day208/206:19}-{Day208/207:3}; {Day209/15:23}-{Day209/17:7}; {Day209/26:4-13}; {Day209/76:5}- {Day209/78:11}; {LFB00118213/11}; Dobson {Day211/186:24}-{Day211/188:21}; {Day211/190:6}-{Day211/192:9}.Show full note AC Cotton described Babcock's inability to develop incident command training as one of her greatest frustrations. She said that the LFB could not take back control of training because it had lost the teams that it had previously relied on for developing courses.²⁹⁰²⁹⁰ Cotton {Day209/76:5}-{Day209/79:12}.

¶72.21 Babcock's lack of expertise clearly contributed to the significant delay in the development and release of the revised incident command training. Peter Groves told us that it should normally take no more than a year to produce a new course but that the complexity of training for incident command and Babcock's lack of expertise had delayed the process. He agreed, however, that a lapse of three years between the receipt of the coroner's recommendations and the release of the Holcroft House exercise was unduly long. He attributed the delay to Babcock's lack of expertise,²⁹¹²⁹¹ Dobson {Day211/127:19}-{Day211/128:14}. but the LFB was ultimately responsible for the protection of life and property and of its own staff and had a duty to ensure that adequate training was provided to its crews for that purpose. Although we heard evidence that Commissioner Dobson had raised the delay with the chief executive of Babcock, they appear to have concluded that neither Babcock nor the LFB was at fault and to have confined themselves to repeating the importance of complying with the coroner's recommendations.²⁹²²⁹² Dobson {Day211/185:23}-{Day211/192:9}. The discussions had little or no effect on the delay. We do not think that the steps taken by the LFB to remedy the problems with Babcock were sufficiently robust.

¶72.22 Some senior LFB officers thought that the coroner's recommendations did not require any substantive revisions to the LFB's existing incident command training. For example, Commissioner Dobson told us that the LFB had not needed to revise its incident command training; all that was needed, he thought, was for the seven recommendations to be enhanced and properly embedded.²⁹³²⁹³ Dobson {Day211/178:12-23}. Similarly, AC Cotton said that the recommendations were not inconsistent with existing policy and procedures²⁹⁴²⁹⁴ Reason {Day181/36:5-17}. and Director Reason did not think that the recommendations reflected the existence of a systemic problem.²⁹⁵²⁹⁵ Reason {Day181/137:1-13}. We think that views of that kind held by senior officers are likely to have undermined the importance attached to the training packages and to have added to the delay.

Incident command revalidation

¶72.23 Another aspect of incident command training that was under development at the time of the Grenfell Tower fire was a programme of continuing assessment of competence to undertake incident command, known as incident command revalidation. The purpose of the programme was to ensure that operational officers of crew manager rank and above maintained the required level of competence as incident commanders throughout their operational careers. That contrasted with the position under the LFB's incident command training arrangements existing at the time of the Grenfell Tower fire, under which competence to undertake incident command was assessed by way of an exercise undertaken only when an officer was being considered for promotion. Under those arrangements no further assessment took place unless and until that officer was being considered for further promotion. None of the continuing incident command training that existed immediately before the Grenfell Tower fire contained any form of assessment, and officers who undertook that training continued in their existing rank regardless of their performance during training.

¶72.24 Proposals for an incident command revalidation programme had first been put forward to the Commissioners' Group by Dr Sabrina Cohen-Hatton, then a DAC and the LFB's Head of Development, in a report dated 17 November 2015.²⁹⁶²⁹⁶ {LFB00118186}. She referred to the declining number of incidents in the years preceding the report, which had resulted in a reduction in operational experience across the board and, in particular, a reduction in the number of opportunities for officers to undertake command roles. Her department had consulted five other fire and rescue services, all of which were operating a revalidation system of some kind involving a formal assessment of competence to undertake incident command roughly every 18 to 24 months.²⁹⁷²⁹⁷ The FRSs consulted were Tyne and Wear, Greater Manchester, Hampshire, Derbyshire and Hertfordshire.

¶72.25 The report to the Commissioners' Group also referred to the remarkably low pass rates for the LFB's existing incident command promotional exercises, in which just 25% of station managers and group managers and 36% of Deputy Assistant Commissioners were successful. Dr Cohen-Hatton said that the low pass rates were likely to be explained by the fact that candidates received no training in how to command an incident of the scale and complexity that they were required to tackle as part of the promotional exercise, meaning that the first time that many of them had encountered such an environment was at the assessment itself.²⁹⁸²⁹⁸ Cohen-Hatton {Day185/125:4-15}.

¶72.26 The report recommended a revalidation programme consisting of three elements: a test to assess levels of technical and procedural knowledge, another test to assess command skills by means of an incident command exercise, and the demonstration by means of a continuing professional development (CPD) log that incident command skills had been consistently and effectively applied on the incident ground. Dr Cohen-Hatton proposed that the three elements should be assessed every two years, with provision for additional training to be undertaken by those who scored below a minimum threshold, or, in the most serious cases, removal from operational duties.

¶72.27 The proposed revalidation programme was developed separately from the work being carried out on the coroner's recommendations, but its implementation depended on the delivery of the new incident command training exercise being developed as part of Babcock's wider review. Since the LFB lacked the necessary resources to provide and assess a separate exercise just for the revalidation programme, the incident command exercise to be used for the revalidation process had to form part of the new incident command refresher training.²⁹⁹²⁹⁹ Cohen-Hatton {Day185/145:11-16}; {Day185/147:1-15}. The delay in the development of the new course therefore delayed the progress of the incident command revalidation programme.

¶72.28 The original timetable for the revalidation programme had been set out in a report to the Corporate Management Board dated 16 December 2015, which recorded that the knowledge tests and the incident command exercise were to be launched in April 2016 and the use of CPD logs in April 2017.³⁰⁰³⁰⁰ {LFB00118193}. However, by the time that Dr Cohen-Hatton reported to the Corporate Management Board on 8 June 2016 those dates had been pushed back to some indeterminate time in 2016 or 2017, in the case of the knowledge tests and incident command exercise, and 2017 or 2018 in the case of the CPD logs.³⁰¹³⁰¹ {LFB00118189}. At a meeting of the Incident Command Project Board on 23 February 2017, Dr Cohen-Hatton expressed her concern that the implementation of a revalidation programme was being pushed back as a result of the delay in the broader review of incident command training.³⁰²³⁰² Cohen-Hatton {LFB00110660/24} page 24, paragraph 87; {LFB00118192/2}. A briefing note prepared for the Corporate Management Board in March 2017 stated that pilots of some of the knowledge tests would be carried out in May 2017 and indicated that a draft policy was in the final stages of development.³⁰³³⁰³ {LFB00118187}; Cohen-Hatton {Day185/163:1-17}. By that stage Dr Cohen-Hatton's team had done most of what they could do pending the delivery of the incident command training being developed in response to the broader review.³⁰⁴³⁰⁴ Cohen-Hatton {Day185/164:4-8}.

¶72.29 The revalidation programme had still not been implemented at the time of the Grenfell Tower fire, nor by the time of the inspection of the LFB by Her Majesty's Inspectorate of Constabulary and Fire and Rescue Service (HMICFRS) in May and June 2019, which identified the lack of any revalidation system as a cause for concern requiring immediate action by the LFB.³⁰⁵³⁰⁵ {INQ00014796/39}.