Chapter 74: The response to the Lakanal House fire

¶74.1 As the chairman explained in Chapter 8 of the Phase 1 report, Lakanal House was a high‑rise residential tower block in Camberwell, South London. On 3 July 2009, a fire broke out in a flat on the ninth floor of the building. Within 30 minutes it had spread down to the fifth floor and up to the twelfth floor as well as to communal areas, including corridors and the building's single staircase. Six people lost their lives and 15 people were taken to hospital suffering from smoke inhalation. The incident involved a widespread failure of compartmentation and extensive spread of fire and smoke.³²⁰³²⁰ Dobson {Day210/73:6-10}. The fire was able to spread across the external wall (both upwards and downwards) as a result of the presence of combustible window panels that did not comply with the Building Regulations.³²¹³²¹ Dobson {Day210/75:8-20}. The incident was also characterised by an unusually high number of fire survival guidance calls (five in total),³²²³²² The LFB's Lakanal Control Report, produced for the purpose of the Lakanal inquests, identified five calls to the control room during which fire survival guidance advice was given {HOM00001124/35-37}. Two of those calls were from the same flat and three of the calls were in progress at the same time. poor communication between the control room and the incident ground, difficulties with radio communications generally and confusion among firefighters about the layout of the building and the locations of flats.³²³³²³ Dobson {Day210/75:21}-{Day210/76:13}.

¶74.2 The Lakanal House fire in July 2009 was a watershed moment for the LFB and was undoubtedly the most significant residential fire in which it had been involved in the years immediately preceding the Grenfell Tower fire. It is of particular importance because it marked a milestone in the history of the LFB's response to fires in high-rise residential buildings and the handling of emergency calls. It prefigured in many respects the Grenfell Tower fire some eight years later and it is therefore appropriate to consider how the LFB responded to the experience and the extent to which it learned from it.

The Lakanal House Board

¶74.3 In October 2009, Commissioner Dobson set up the Lakanal House Board to oversee the LFB's internal investigation into the fire and its response to it. It was chaired by the Commissioner and attended by a wide range of senior officers. The board was responsible for identifying the lessons to be drawn from the incident and for making any recommendations for organisational change that were thought necessary.³²⁴³²⁴ {LFB00039696} Lakanal House Board Terms of Reference; Dobson {Day210/79:3}-{Day210/80:15}. It met monthly and provided a forum for senior officers to discuss matters arising from the LFB's investigation into the fire, to agree a response and to allocate responsibility for action to relevant departments and officers.³²⁵³²⁵ Dobson {Day210/86:21}-{Day210/87:3}.

¶74.4 The Lakanal House Board identified 34 steps that could be taken to improve the LFB's operational response. They were set out in an action plan agreed at a meeting of the Board on 15 September 2010. Each step was assigned to an officer who was responsible for its implementation.³²⁶³²⁶ {LFB00084031/7-10}. At subsequent meetings those officers provided regular reports on progress which were reflected in a rolling plan of action.³²⁷³²⁷ {LFB00084032/5-8}. The 34 steps became known internally as the "pre-inquest actions", or simply "pre-actions". They covered a wide range of subjects, from the development of a policy relating to the risk of falling cables to writing to the government to obtain clarity on aspects of national guidance. They included a review of the LFB's existing policies on firefighting in high-rise buildings and the management of emergency calls. Although some are of no relevance to our investigations, others are of central importance, such as the review of the LFB's policy on firefighting in high-rise buildings and the provision of training to control room officers in handling fire survival guidance calls. However, the pre-inquest actions failed to include any response to what should have been the principal concerns arising from the Lakanal House fire, namely, the widespread failure of compartmentation and the spread of fire across external walls due to the use of combustible construction materials.

The Lindridge Review

¶74.5 In September 2012, more than three years after the fire and in preparation for the Lakanal House inquests, Commissioner Dobson asked the Operational Assurance department, then headed by AC Cotton, to review the pre-actions to identify those which had been completed and those which had not.³²⁸³²⁸ Dobson {LFB00032157/10} page 10, paragraph 38; Reason {LFB00032747/18} page 18, paragraph 53; Dobson {Day211/153:12-24}. Director Reason (to whom AC Cotton reported) delegated the task of carrying out the review to GM David Lindridge,³²⁹³²⁹ Lindridge {LFB00083925/4} page 4, paragraph 17. subject to the oversight of AC Cotton.³³⁰³³⁰ Cotton {LFB00032737/6} page 6, paragraph 21.

¶74.6 GM Lindridge understood that his review was to involve no more than identifying which pre-actions had been carried out and which had not. He did not express a view on whether the actions taken were sufficient to meet the expectations of the board; he simply described the steps that had been taken so that others could make that assessment for themselves.³³¹³³¹ Lindridge {LFB00083925/3} page 3, paragraph 12.

¶74.7 In January 2013, GM Lindridge produced a report of his findings entitled Review of the Lakanal Action Plan (the Lindridge Review).³³²³³² {LFB00033943}. He found that 16 of the 34 tasks were still being worked on in one way or another and was unable to confirm that another 13 had achieved their expected outcomes.³³³³³³ {LFB00033943/4-5} pages 4-5, paragraphs 5.2 and 5.3. GM Lindridge attached to his report a list of the pre‑actions together with his findings on each of them. He also set out a list of his key findings in relation to ten of the pre-actions for the attention of the Commissioner's Group. Most of them related to the control room.

¶74.8 GM Lindridge produced a revised version of his report in November 2013, in which he found that 8 actions had still not been completed (although in all but one of those cases the LFB was awaiting action by another organisation).³³⁴³³⁴ {LFB00083988}. They included actions concerning the training of control room supervisors, pre-planning and correspondence with the government relating to aspects of fire safety.³³⁵³³⁵ {LFB00083988/6-23}.

¶74.9 After receiving the Lindridge Review, neither AC Cotton nor anyone else appears to have considered whether the implementation of the Lakanal pre-inquest actions had been effective. Commissioner Cotton said that she had not been sufficiently qualified in a number of the areas being audited to express an opinion. In her view, it was the function of the Lakanal House Board to satisfy itself that the work had been done. She did not see it as part of her role as Head of Operational Assurance to be concerned with the detail of the actions referred to in the Lindridge Review.³³⁶³³⁶ Cotton {Day208/110:10}-{Day208/111:6}.

¶74.10 In the event, the Lindridge Review was never presented to the Lakanal House Board, which held its last meeting in September 2013 (though it was never formally disbanded). Commissioner Dobson said that his intention had been to have a final meeting formally to review and accept the revised Lindridge Review, but that it had been overlooked.³³⁷³³⁷ Dobson {Day211/171:3}-{Day211/172:7}. Nor was the Lindridge Review ever presented to the Lakanal House Working Group, referred to below, because the working group was directing its attention to the steps required in response to the findings made by the coroner.³³⁸³³⁸ Reason {Day180/130:19-25}; Dobson {Day211/172:8-25}.

¶74.11 Although Commissioner Dobson said that responsibility for overseeing the progress of outstanding pre-inquest actions had been taken over by the co-ordination board,³³⁹³³⁹ Dobson {Day210/88:15}-{Day210/89:5}; {Day211/171:24}-{Day211/172:4}. we have seen no evidence of any such oversight in the minutes of its meetings. The Lindridge Review was, however, circulated to the Commissioner's Group and discussed at a meeting in November 2013.³⁴⁰³⁴⁰ Reason {Day180/130:15-18}. Director Reason's recollection was that he and Deputy Commissioner Dexter had each accepted responsibility for the outstanding actions that fell within their respective directorates.³⁴¹³⁴¹ Reason {LFB00032747/19} page 19, paragraph 58; Reason {Day180/132:4}-{Day180/133:6}.

¶74.12 After the Lakanal House Board effectively ceased to exist in September 2013, the LFB was left with no means of ascertaining whether the outstanding pre-inquest actions had been completed. Nor did it carry out any systematic inquiry to find out whether the work that had been done had been successful in making good the deficiencies the fire had uncovered. As a result, by 14 June 2017 significant steps that were relevant to dealing with the hazards that were later to confront the LFB at Grenfell Tower had not been taken. The LFB's failure effectively to oversee the progress and completion of the changes in training and procedure it had identified as necessary in the light of the Lakanal House fire was a significant failing which prevented it from responding more effectively to the fire at Grenfell Tower.

¶74.13 Commissioner Cotton told us that monitoring the work on the Lakanal pre-inquest actions had not been the responsibility of the Operational Assurance department.³⁴²³⁴² Cotton {Day208/114:5-19}. Although that may be true, it is unfortunate that the department responsible for ensuring the operational effectiveness of the LFB (and with learning from significant incidents) did not have, and did not seek, that responsibility, especially as no other department of the LFB did. Operational Assurance was the department to which the Commissioner had assigned responsibility for the review of the 34 pre-inquest actions in the first place and Commissioner Dobson should have ensured that there was no doubt about where responsibility for overseeing the implementation of the Lakanal pre-inquest actions lay. Ms Cotton had also been a member of the Lakanal House Board and she continued to sit on the co-ordination board, two key boards attended by the heads of service responsible for implementing the various changes. The Operational Assurance department was best placed to oversee the necessary changes, with the assistance of relevant experts where required, and to monitor the progress of any that remained outstanding. The Commissioner's failure to assign responsibility clearly to the Operational Assurance department was a significant error.

¶74.14 There is no evidence that the LFB subsequently reviewed the 34 pre-inquest actions in the light of the Lakanal House coroner's recommendations to see whether further changes might be required.³⁴³³⁴³ Cotton {Day208/139:1-22}.

The Lakanal House inquests and the coroner's rule 43 letter

¶74.15 The Lakanal House inquests were conducted by Her Honour Frances Kirkham CBE between January and March 2013. The coroner heard evidence from a number of LFB witnesses, including Commissioner Dobson.

¶74.16 Rule 43 of the Coroners Rules then in force allowed the coroner to make such recommendations as she considered necessary, based on the evidence heard during the inquest, to eliminate or reduce the risk of further deaths. On 28 March 2013, she sent Commissioner Dobson a letter pursuant to that rule (a rule 43 letter).³⁴⁴³⁴⁴ {LFB00032158}. She also wrote to the Department for Communities and Local Government, the London Borough of Southwark and the Fire Sector Federation.

¶74.17 In her letter to the Commissioner the coroner acknowledged the work that the LFB had already carried out and recommended further action in five areas: public awareness of fire safety, visits made pursuant to section 7(2)(d) of the Fire and Rescue Services Act 2004, incident command, the control room, and communications. The substance of those recommendations will be considered in later chapters.

¶74.18 Following receipt of that letter, Commissioner Dobson instructed Director Reason to put together an action plan in response to the coroner's recommendations.³⁴⁵³⁴⁵ Reason {LFB00032747/5} page 5, paragraph 19. In April 2013, Director Reason held a meeting with the heads of service responsible for the activities in question and asked each of them to produce a draft plan of action on the recommendations affecting their areas of responsibility.³⁴⁶³⁴⁶ Reason {Day180/139:2}-{Day180/140:21}. Draft plans, referred to internally as "pro formas", were produced by four heads of service, AC David Brown (Head of Operations, Procedures and Response), AC Stephen Turek (Head of Fire Safety Regulation), AC Dany Cotton (Head of Operational Assurance), and AC James Knighton (Head of Operational Procedures). They contained an analysis of the recommendations and proposed responses.³⁴⁷³⁴⁷ {LFB00073406}; {LFB00034062}. The pro formas were submitted to the Commissioner's Group, which used them to draft the LFB's response to the coroner's letter.³⁴⁸³⁴⁸ Reason {Day180/141:5}-{Day180/142:16}. That response was discussed and approved at a meeting of the Commissioner's Group and the heads of service on 14 May 2013. The meeting was not minuted, but Director Reason's recollection was that it had been concerned principally with the Commissioner's review of the proposals and the time required to implement them.³⁴⁹³⁴⁹ Reason {Day180/142:9}-{Day180/143:7}.

¶74.19 On 23 May 2013, Commissioner Dobson sent the LFB's response to the coroner.³⁵⁰³⁵⁰ {LFB00042089}. The letter set out the action which the LFB proposed to take in response to each recommendation and the time within which it would be completed. The Commissioner estimated that all the proposed actions would be completed by the end of 2013.

¶74.20 Responsibility for overseeing the progress of the steps that the LFB proposed to take was allocated to the co-ordination board and the Lakanal House Working Group.³⁵¹³⁵¹ Reason {LFB00032747/6} page 6, paragraph 22. (One of the co-ordination board's existing functions was to monitor the progress of proposals for responding to rule 43 recommendations.)³⁵²³⁵² Reason{Day180/145:6}-{Day180/146:8}. At a meeting of the board on 3 June 2013 it was agreed that AC Cotton would develop a plan to monitor the progress of the response to the coroner's recommendations.³⁵³³⁵³ Cotton {LFB00032737/7} page 7, paragraph 25. A consolidated plan combining the response to the coroner with the LFB's reaction to some rule 43 recommendations made by the Hampshire coroner following a fire at Shirley Towers in Southampton in which two firefighters had died was therefore produced for a meeting of the co-ordination board on 4 July 2013.³⁵⁴³⁵⁴ {LFB00089127}.

¶74.21 Commissioner Dobson told us that he took personal responsibility for overseeing the response to the coroner's letter, which, in addition to his role on the working group, he exercised in the course of meetings with individual directors and through the Commissioner's Group.³⁵⁵³⁵⁵ Dobson {LFB00032157/7} page 7; Dobson {Day210/100:14}-{Day210/101:3}.

¶74.22 Overall, the response of the LFB to the Lakanal House fire was slow and ineffective. Although it soon established a process for identifying the lessons to be learnt and the steps needed to implement them, it took the best part of a year for it to identify those steps, several of which had not been implemented by the time that the first Lindridge Review was delivered two years later. Some had still not been implemented by the time that GM Lindridge produced his revised review in November 2013. The Lakanal House Board appears to have been allowed to lapse without any proper consideration of the extent to which the recommendations had been implemented, much less whether they had been successful. In our view, senior officers failed to provide the energetic and effective response that was required to an incident of such significance, for which Commissioner Dobson must bear primary responsibility.

The Lakanal House Working Group

¶74.23 The Lakanal House Working Group was established by LFEPA in June 2013 to review and oversee the LFB's actions following the fire at Lakanal House and to provide regular information and any additional recommendations to LFEPA's Strategy Committee.³⁵⁶³⁵⁶ {LFB00032156/3}. It consisted of three elected members of the authority, Valerie Shawcross, Maurice Heaster and Peter Truesdale.³⁵⁷³⁵⁷ Dobson {LFB00032157/7} page 7, paragraph 23; {LFB00032156/3}. The working group was intended to provide political oversight, scrutiny and accountability for the LFB's response to the coroner's recommendations.³⁵⁸³⁵⁸ Reason {Day180/148:18-23}; Dobson {Day210/96:7-18}. Although membership of the working group was formally limited to the three elected members, its meetings were also attended by Commissioner Dobson, Deputy Commissioner Dexter, Director Reason and other senior LFB officers as required in order to provide information on progress and answer members' questions.

¶74.24 The outstanding pre-inquest actions were never brought to the attention of the working group, nor did it receive a copy of the Lindridge Review. When Director Reason was asked whether the working group might have benefited from seeing the review or from being told about the items that remained outstanding, he said that the elected members would probably not have wanted that level of information.³⁵⁹³⁵⁹ Reason {Day180/131:6}-{Day180/132:3}; {Day180/133:7-22}.

¶74.25 Director Reason was responsible for presenting a report on the progress of the response to the coroner's rule 43 letter at each meeting of the working group and reporting the current position in each case.³⁶⁰³⁶⁰ Reason {LFB00032747/7-8} pages 7-8, paragraphs 27 and 30. He said that his reports had been based on those that had been provided to the co-ordination board, presented in a slightly different way.³⁶¹³⁶¹ Reason {Day180/151:4-8}. In reality, the difference was more than slight. The reports submitted to the working group did not provide its members with an accurate summary of the LFB's incomplete progress in responding to the rule 43 letter. Most notably, as we have set out in detail in Chapter 72, some reports provided to the working group were misleading because they indicated that important changes to incident command training had been completed, when that was far from the case.

¶74.26 The Lakanal House Working Group met six times between July 2013 and March 2014. LFEPA's Strategy Committee was told about the LFB's actions on only two occasions, once in November 2013,³⁶²³⁶² {LFB00089117}. when work was still continuing, and once in July 2014.³⁶³³⁶³ {LFB00029746}. That was clearly at odds with the working group's objective of providing information to the Strategy Committee regularly.³⁶⁴³⁶⁴ {LFB00032156/3}.

¶74.27 At its meeting in July 2014, the Strategy Committee received a report from Deputy Commissioner Dexter and Director Reason. The report summarised the LFB's work in response to the coroner's recommendations, recorded that the members of the working group were satisfied that they had fulfilled its original purpose and recommended that it be wound up.³⁶⁵³⁶⁵ {LFB00067819/1}, {LFB00067819/5}. That recommendation was accepted and the working group was formally closed. However, the 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.

¶74.28 Director Reason said that he had not intended to mislead the Strategy Committee and that it had not been the purpose of the report to rehearse all the information that had been put before the working group, merely to give a flavour of the subjects that had been covered.³⁶⁶³⁶⁶ Reason {Day181/143:6}-{Day181/144:11}. He also told us that the members of the working group had been less interested in the details of operational procedures, policy and training than in wanting to understand broadly what the LFB had been doing.³⁶⁷³⁶⁷ Reason {Day181/144:12-18}. We found his explanation unconvincing. The report presented to the Strategy Committee was not merely short on detail; it was, for the reasons summarised above and set out in greater detail in Chapter 72, misleading. With the closure of the working group, the report also ended active scrutiny by LFEPA of the outstanding responses to the rule 43 letter.³⁶⁸³⁶⁸ Reason {Day181/147:15-25}. Director Reason said that it had not been the LFB but the members of the working group who had decided that it should be closed down, because, based on the information they had been given, they were satisfied that they had completed what they had set out to achieve.³⁶⁹³⁶⁹ Reason {Day181/144:3}-{Day181/146:13}. However, for the reasons we have given, that information was incomplete and therefore misleading. Although we accept that was not Director Reason's intention, it was the practical effect of providing incomplete reports.

¶74.29 In fact, certain steps identified by the LFB as necessary in response to the coroner's rule 43 letter remained outstanding at the time of the Grenfell Tower fire. In July 2014, the Lakanal House Working Group could and should have been given an accurate summary of the extent to which the LFB had implemented the various changes required in response to the Lakanal House fire. If it had been given that information, it would have been obvious to the working group that the LFB had not responded fully to the coroner's recommendations. By failing to provide it the LFB denied members of the working group the opportunity to challenge the Commissioner about the LFB's dilatory and incomplete progress and, more broadly, prevented them exercising their public duty of holding the LFB to account. We are satisfied that the closure of the working group and the consequent lack of active scrutiny by LFEPA contributed to the LFB's failure to implement the coroner's recommendations fully. That lack of scrutiny was compounded by the LFB's failure to complete its own pre-inquest actions. Not only did the LFB fail to learn from the Lakanal House fire, the premature end of the Lakanal House Working Group ensured that its failure properly to oversee the progress and completion of the steps that it had itself identified as necessary went unremedied.

The lessons – Spread of fire over external walls

¶74.30 The Lakanal House fire demonstrated, if not for the first time then beyond any lingering doubt, that combustible facade panels could enable fire to spread through the external wall of a high-rise building and that a failure of effective compartmentation, whether resulting from combustible facade panels or otherwise, could lead to the rapid total failure of a building. Understanding those risks, which were later to be exemplified in the Grenfell Tower fire, was essential, given the increasing prevalence of modern materials and methods of construction. We have therefore considered it appropriate to examine the extent to which the LFB understood the significance of the Lakanal House fire and how it affected its understanding of the hazards posed by combustible facade panels.

¶74.31 By December 2009, the LFB was aware that other buildings in London might be constructed of materials that would allow fire to spread rapidly across the external walls and result in a consequent widespread failure of compartmentation. Indeed, the exchange between Commissioner Dobson and Sir Ken Knight during December 2009 was prompted by the LFB's belief that the regulatory regime was inadequate or was being widely ignored.³⁷⁰³⁷⁰ {LFB00123737/11} page 11, paragraph 26.

¶74.32 When Commissioner Dobson was asked why the LFB had not taken steps at the time to advise its operational crews how to respond to the spread of fire across the external wall of a building, he said that he did not think that the way in which the fire had spread at Lakanal House had been unusual and that firefighters would not have been surprised to see the fire spread in the way it did, although they might have been surprised by the speed at which it had happened. He did not think there had been anything particularly unusual about the Lakanal House fire that crews needed to be notified of.³⁷¹³⁷¹ Dobson {Day210/131:18}-{Day210/132:9}; {Day210/132:16}-{Day210/133:5}.

¶74.33 We do not agree with the Commissioner's assessment. Other witnesses told us that the spread of fire downwards at Lakanal House had been unusual. For example, Dr David Crowder described it as very unusual and not something that had been encountered commonly, if at all, previously.³⁷²³⁷² Crowder {Day230/4:15-21}. Sir Ken Knight said that it had been almost unique.³⁷³³⁷³ Sir Ken Knight {Day245/187:11-13}. Furthermore, it is clear that the crews at Lakanal House were surprised by both the speed and the direction in which the fire had spread.³⁷⁴³⁷⁴ This was clear from firefighters' evidence at the inquests following the Lakanal House fire: https://www.lambeth. gov.uk/about-council/transparency-open-data/lakanal-house-coroner-inquest. Given that the LFB knew about the use of combustible panels in external walls and the risks associated with them, crews should have been expressly warned about the danger of fire spreading across them and the consequent risk of compartmentation failure.

The lessons - Failure of compartmentation

¶74.34 National operational guidance on firefighting in high-rise buildings is to be found in Generic Risk Assessment (GRA) 3.2 issued by the DCLG. The version of GRA 3.2 in force at the time of the Lakanal House fire, published in September 2008, had identified the failure of compartmentation and the potential need for multiple rescues as an event for which contingency plans ought to be developed.³⁷⁵³⁷⁵ {HOM00002128/12}. At the Lakanal House inquests, however, Commissioner Dobson told the coroner that under normal circumstances operational firefighters would expect a fire in a high-rise residential building to remain within the compartment of origin and not to enter communal areas before crews could reach the compartment and attack the fire.³⁷⁶³⁷⁶ Johnson, Expert Communications Report {CWJ00000010/83} page 83. He said that crews would have been aware that the fire might spread to flats immediately above the fire flat, but would not expect it to spread to flats that were adjacent to the flat of origin.³⁷⁷³⁷⁷ Johnson, Expert Communications Report {CWJ00000010/35} page 35. Peter Holland, who was the Chief Fire and Rescue Adviser at the time of the Lakanal House inquests, told the coroner that, although the compartmentation of a building was sometimes not as good as it was designed to be, a failure of compartmentation was an infrequent rather than a regular occurrence.³⁷⁸³⁷⁸ {HOM00045826/34-35} page 34-35.

¶74.35 On 9 July 2009, six days after the Lakanal House fire, Commissioner Dobson sent a letter to the housing departments of all London boroughs, housing associations and other social housing providers referring them to AC Turek's letter of 23 March 2009.³⁷⁹³⁷⁹ {LFB00001232}. In his letter he reminded recipients about certain fire safety matters, including the need for a suitable and sufficient risk assessment, which the letter said should include consideration of compartmentation, particularly where it protected escape routes. He also reminded them that a risk assessment should be reviewed if any material change was made to the premises, including any changes to the compartmentation arrangements or refurbishment.

¶74.36 In that letter the Commissioner drew attention to the need to have an evacuation strategy appropriate to the circumstances of the individual premises, but he emphasised that it should be safe for residents to remain in their flats if a fire occurred elsewhere in the building, providing that the premises complied with both the Building Regulations and the Fire Safety Order and suitable management and maintenance procedures were in place.

¶74.37 Commissioner Dobson agreed that when that letter had been written the early indication from the LFB's own investigations had been that a failure of compartmentation had been one of the primary reasons for the spread of fire at Lakanal House and that he had been concerned that other buildings in London might suffer from the same defect.³⁸⁰³⁸⁰ Dobson {Day210/119:17}-{Day210/120:1}. However, he said that the reference to strategies for evacuating buildings had not been intended to suggest that a "stay put" strategy might not be appropriate for such buildings; rather, it had been prompted by the LFB's understanding that the escape balconies at Lakanal House had not been used by residents because they had not been aware of their purpose.³⁸¹³⁸¹ Dobson {Day210/120:11-21}.

¶74.38 The widespread failure of compartmentation at Lakanal House was also identified in the action plan drawn up by the Lakanal House Board. Item 20 required the LFB's Fire Safety department to carry out a review of high-rise fires involving the spread of fire beyond the compartment of origin to identify those incidents which could have provided opportunities for learning before 3 July 2009.³⁸²³⁸² {LFB00004801/16} page 16, action 20; {LFB00033943/15} page 15, action 20. DC Dexter said that that had been a response to both the spread of fire that had occurred at Lakanal House and to emerging findings reported by the Fire Safety team.³⁸³³⁸³ Dexter {Day179/82:21-25}. Given the contents of AC Turek's letter, it is surprising that a search of the LFB's incident management system had not revealed any record of a high‑rise incident at which fire had spread by mechanisms similar to those identified at Lakanal House.³⁸⁴³⁸⁴ {LFB00004801/16} page 16, action 20, {LFB00051803/135}; see also {LFB00033943/15} page 15, action 20. DC Dexter later questioned that finding with the LFB's Information Management department, which was responsible for collating and managing data of that nature.³⁸⁵³⁸⁵ {LFB00096647}. In response, Clive Eustice, a member of the department, expressed doubt about the absence of any such records, which he thought reflected a very lazy response. Mr Eustice said that on being given the relevant criteria the department could provide a report setting out the relevant incidents, but no such report was made available to us.

¶74.39 When she was asked why she had raised the matter with the Information Management department, DC Dexter said that, having read a number of fire investigation reports, she could see that there had been breaches of compartmentation or the spread of fire beyond the compartment of origin and thought it unlikely that no incidents of that kind could be identified.³⁸⁶³⁸⁶ Dexter {Day179/86:12-23}. There is evidence that she did in fact obtain some data as a result of her inquiries and that she questioned whether Item 20 had been clearly defined.³⁸⁷³⁸⁷ {LFB00083970}. Ultimately, however, the LFB concluded that there was no record of a high-rise incident at which fire had spread in ways similar to those at Lakanal House.

¶74.40 The conclusion that there had been no similar incidents before the Lakanal House fire was inconsistent with AC Turek's letter of 23 March 2009. It was also inconsistent with concerns that were being discussed both within the LFB itself and by the LFB with outside bodies soon after the Lakanal House fire. On or around 21 April 2010, there was a meeting at the LFB's headquarters between Commissioner Dobson and representatives of the construction industry, local authority building control, and representatives of the DCLG, including Brian Martin. AC Turek wrote a briefing note for the Commissioner in advance of the meeting which said that its purpose was to discuss the LFB's concerns about the quality of construction and checking of newly built and newly refurbished residential properties.³⁸⁸³⁸⁸ {LFB00025654/13-14}. Those concerns resulted from a significant number of fires during the previous two years which had exhibited an unusual spread of smoke or fire. The note stated that the causes had often been identified as breaches of the Building Regulations, either during construction or refurbishment, and that the fires had led to people becoming trapped and requiring rescue, the collapse or other unnecessary damage to buildings and to firefighters' being placed at unnecessary risk. There had been about 50 significant cases in the London area, most of which were said to have involved major construction companies. The note referred to the concern felt within the LFB about whether the regulations covering the construction and approval of building work were being enforced with sufficient vigour to ensure that new residential buildings in London were fit for their purpose, as well as to concern about how many such buildings there might be in the city.

¶74.41 The briefing note did not provide details of any of those significant cases in London, but other evidence suggests that the fire at Bush House on 2 February 2007 had prompted the meeting. Bush House was a six-storey, newly constructed residential block. A fire had started in the basement parking area and entered a service shaft, through which it spread vertically to all floors of the building, including the building's only escape route, resulting in residents having to be rescued by the fire brigade from the balconies of their flats.³⁸⁹³⁸⁹ {LFB00025654/3} page 3. As a result of the concerns raised by that and other similar incidents, those present at the meeting agreed that the National House Building Council (NHBC), in conjunction with the Chief Fire Officers Association, would provide training to raise awareness of the need for effective fire stopping. That training was provided in 2011.³⁹⁰³⁹⁰ {LFB00025654/3} page 3, paragraph 18.

¶74.42 Commissioner Dobson was unable to recall any details of the meeting, but he agreed that by April 2010 the LFB had identified the risk across the built environment of failure to comply with the Building Regulations and was aware that it had resulted in a significant number of fires in London.³⁹¹³⁹¹ Dobson {Day210/135:13-24}. He told us that the way in which the fire had spread at those incidents had been predictable, given the defects in the buildings,³⁹²³⁹² Dobson {Day210/135:24}-{Day210/136:2}. and he agreed with DC Dexter that the failure of compartmentation was common, although for a wide range of reasons.³⁹³³⁹³ Dobson {Day210/136:4-9}. Nonetheless, the LFB did not seek to communicate the existence of those defects or their concerns about defective buildings to operational crews. Commissioner Dobson said that he had had concerns about the proliferation of guidance and information given to operational crews, because complaints had been made in the past that guidance notes often duplicated or conflicted with one another.³⁹⁴³⁹⁴ Mr Dobson was referring to observations made by Mr Justice MacDuff, the judge who presided over the trial of the incident commanders at the Atherstone-on-Stour fire in November 2007 and was critical of the large volume of operational guidance notes and other materials considered during the trial, Dobson {Day210/140:4-25}; see also {LFB00046278/21}. Mr Dobson also told us that in any event, the spread of fire as a result of inadequate compartmentation would generally not be a surprise to operational firefighters.³⁹⁵³⁹⁵ Dobson {Day210/141:1-22}.

¶74.43 Although the Commissioner's concern not to over burden operational crews with excessive guidance was understandable, we think it would have been possible to communicate to crews in a simple way that the LFB was coming across a significant number of buildings that did not comply with the Building Regulations and that crews therefore needed to be ready for smoke and fire to spread in unusual ways as a result of a failure of compartmentation. That would have sent a clear message that was consistent with national guidance and, more importantly, would have reflected the dangers that the LFB was encountering on the ground. If there was an unhelpfully large amount of operational guidance in circulation, the LFB should have taken steps to reduce it, but that was not a good enough reason not to draw the attention of operational personnel to concerns about inadequate compartmentation that were very much in the minds of those at senior management level.

¶74.44 Inadequate compartmentation in residential high-rise buildings continued to be a concern to the LFB throughout its investigations into the Lakanal House fire. On 11 December 2012, Commissioner Dobson wrote to Brandon Lewis MP, then Parliamentary Under-Secretary of State with responsibility for fire and resilience,³⁹⁶³⁹⁶ {LFB00032154}, Brandon Lewis {Day257/3:4-7}. setting out seven recommendations that the LFB thought should be considered by the government. The first was that the government should provide further guidance on which parts and areas of buildings containing multiple domestic premises could be described as 'parts used in common' for the purposes of the Fire Safety Order and how that order was intended to operate in relation to premises where the responsible person did not necessarily have control over features affecting the common parts or common fire precautions. Commissioner Dobson said that the recommendation had been identified by the LFB following the failure of compartmentation that had occurred at Lakanal House and, in particular, the fact that the fire had spread from the flat of origin into the adjacent corridor much faster than it would have expected.³⁹⁷³⁹⁷ Dobson {Day210/152:23}-{Day210/153:5}. We consider the other recommendations in the letter elsewhere.³⁹⁸³⁹⁸ See Part 2, Chapter 9.

¶74.45 In her rule 43 recommendations the coroner at the Lakanal House inquests also identified a failure of compartmentation as a matter that required greater consideration by both the LFB and DCLG. In her letter to the LFB, she recommended that consideration be given to the training of incident commanders and potential incident commanders to enhance their performance in seven specific respects, including the ability to recognise that a fire might behave in a manner inconsistent with the principle of compartmentation.³⁹⁹³⁹⁹ {LFB00032158}. The LFB's response to that recommendation is considered below. In her letter to DCLG, the coroner recommended that consideration be given to reviewing GRA 3.2 to provide consolidated national guidance on four particular matters, including awareness that insecure compartmentation can permit the transfer of smoke and fire between a flat or maisonette and common parts of high-rise residential buildings, which has the potential to put the lives of residents and others at risk.⁴⁰⁰⁴⁰⁰ {CLG00000401/2}. In the event, the LFB effectively took charge of the review of GRA 3.2 following the Lakanal House fire.

¶74.46 It is clear from her rule 43 letter that the coroner considered that operational crews, and incident commanders in particular, needed to be prepared for the risk that compartmentation within a high-rise residential building might fail, even though Commissioner Dobson had told her that in his view it remained appropriate to base plans for firefighting and rescue operations on the assumption that compartmentation would be effective. The coroner did not find that the LFB should have reversed the "stay put" advice to residents or that it should have evacuated the building, but in the DCLG's response to the rule 43 letter sent to the coroner on 20 May 2013 by the Rt. Hon. Eric Pickles MP, Secretary of State for Communities and Local Government, there was explicit recognition of the possibility that "stay put" might no longer be a tenable strategy if there were a failure of compartmentation. Referring to the pending review of GRA 3.2, the letter confirmed that the revised guidance would include advice to incident commanders to inform decisions on evacuation, should it become clear during an incident that the "stay put" principle was no longer tenable.⁴⁰¹⁴⁰¹ {HOM00047743}.

¶74.47 In contrast, it appears that no-one within the LFB gave any serious thought to the potential limitations of the "stay put" strategy either before or after the Lakanal House fire, notwithstanding the concerns expressed within the organisation about inadequate compartmentation and the rapid spread of smoke and fire that had occurred at Lakanal House. AC Daly, the head of the Fire Safety department at the time of the Grenfell Tower fire, rightly acknowledged that the "stay put" strategy is absolutely dependent on effective compartmentation.⁴⁰²⁴⁰² Daly {Day183/157:3-4}. The LFB's own documents, even those which pre-dated the Lakanal House fire, such as AC Turek's letter of 23 March 2009, referred to breaches of compartmentation that were significant and posed a real threat to residents' safety. Those concerns should have prompted an analysis by the LFB of the circumstances in which a "stay put" strategy would need to be kept under review, and potentially abandoned, during the course of an incident.

¶74.48 It is not clear why the LFB failed to undertake such an analysis following the Lakanal House fire. On the one hand, there was sufficient concern within the organisation about inadequate compartmentation for it to call a meeting with government and industry in April 2010; on the other, senior officers appear to have assumed that operational personnel were accustomed to dealing with failures of compartmentation when they occurred. Consequently, no serious thought was given to sharing with station-based crews the concern of senior officers about the prevalence of inadequate compartmentation in London or the potentially very serious consequences that could follow if compartmentation were to fail.

The response – The Lakanal House Case Study

¶74.49 In the light of the Lakanal House inquests it became clear to the LFB that there was a need to provide additional training to firefighters and more senior officers in responding to events of the kind that had occurred at that fire. A training package was therefore produced known as the Lakanal House Case Study.⁴⁰³⁴⁰³ {LFB00004801/29} page 39, action 3c. It was commissioned in June 2013, but staff did not start to receive training until July or August 2014, over a year later and five years after the fire.⁴⁰⁴⁴⁰⁴ Reason {Day181/14:18-19}. The case study consisted of a computer-based training package for station-based staff and a half-day presentation for those of station manager rank and above.⁴⁰⁵⁴⁰⁵ {BAB00000073}; {LFB00030044}.

¶74.50 In 2018 the LFB produced a report for the Inquiry containing a review of the action it had taken in response to the Lakanal House fire.⁴⁰⁶⁴⁰⁶ {LFB00004801}. Both that report and several LFB witnesses⁴⁰⁷⁴⁰⁷ {LFB00004801/13} page 13, action 6; {LFB00004801/15} page 15, action 14; {LFB00004801/17-18} pages 17- 18, actions 21-23; Reason {Day180/177:9}-{Day180/178:6}, {Day180/208:10}-{Day180/209:8}, {Day181/37:16}- {Day181/38:17}, {Day181/88:18}-{Day181/89:13}; Daly {Day184/11:11-17}, {Day184/126:5-19}; David Brown {Day187/73:23}-{Day187/75:16}; Cowup {Day195/116:11-20}; Cotton {Day208/194:13-17}; Dobson {Day211/6:6-11}, {Day211/11:24}-{Day211/12:4}.Show full note suggested that a wide range of measures that had been taken in response to the fire had been covered in the case study, but that was not correct, because it dealt with only a relatively narrow range of operational topics, in particular:

¶a. the confusion caused by the unusual layout of the flats at Lakanal House and the need for effective pre-planning;

¶b. the unusual downward spread of fire caused by falling burning debris and the resulting need to move the bridgehead to a lower floor;

¶c. the difficulties arising from the large amount of information that had been received from residents, as well as information relating to fire survival guidance calls, and the need for clear two-way communication between the control room and the incident ground; and d. the consequent difficulties in carrying out search and rescue operations.

¶74.51 The case study did not provide any or adequate training in the following important operational matters in respect of which the Lakanal House fire had exposed weaknesses: a. recognising when a fire might behave in a manner inconsistent with the principle of compartmentation;

¶b. understanding the dangers arising from a widespread loss of compartmentation or the spread of fire across an external wall (apart from drawing attention to the possible need to move the bridgehead due to downward fire spread, as had occurred at Lakanal House);

¶c. understanding the dangers arising from the use of combustible panels in external walls, whether cladding panels or, as was the case at Lakanal House, window infill panels; and d. the correct handling of fire survival guidance calls by control room staff.

¶74.52 Director Reason said that the risk of a failure of compartmentation had been implicit in the training,⁴⁰⁸⁴⁰⁸ Reason {Day180/208:17}-{Day180/209:8}. that the whole package had been concerned with recognising when compartmentation had failed,⁴⁰⁹⁴⁰⁹ Reason {Day180/209:3-4}. and that the graphics and all the material used in the package had been self-evident⁴¹⁰⁴¹⁰ Reason {Day180/210:11-16}. or otherwise should have been obvious to firefighters.⁴¹¹⁴¹¹ Reason {Day180/196:4}-{Day180/197:8}; {Day180/205:16)-{Day180/206:24}; {Day180/208:10)-{Day180/211:10}; {Day181/3:5}-{Day181/8:16}; Cotton {Day208/192:3}-{Day208/193:8}; {Day208/194:13}-{Day208/195:23}. However, the contents of the package do not, in our view, bear that out. They did not make it clear that compartmentation could not always be relied on and did not provide guidance on how to identify or deal with a failure of compartmentation. Those omissions, together with the emphasis on the Lakanal House fire being highly unusual, tended to perpetuate the assumption that compartmentation in high-rise buildings could be relied on.

¶74.53 The omission of any reference in the package to the dangers arising from the use of combustible panels in external walls is particularly surprising in view of the fact that Commissioner Dobson had written to the government in December 2009 expressing the LFB's concern about compliance with the Building Regulations in general and the particular risks posed by certain kinds of external cladding. By that time the LFB had discovered that other buildings in London might be constructed from materials that could result in the rapid or unusual spread of fire across or through external walls.

¶74.54 The present Commissioner, Andrew Roe, suggested that the case study was more sophisticated than might appear from the slides that had been put to certain LFB witnesses. He pointed out that the computer-based package had been accompanied by a training guide and that use had been made of the radio messages sent during the incident as well as interviews with principal officers who had attended the fire.⁴¹²⁴¹² {LFB00123737/47} page 47, paragraph 131. Although they may have made the training more engaging and provided an insight into the attending officers' experience, they did not make up for the omissions identified above.

¶74.55 Commissioner Roe rightly accepted that the case study should have dealt with the failure of compartmentation on a widespread scale and the danger of external fire spread, both of which had played a critical part in the Lakanal House fire. He accepted that knowledge held by one part of the organisation should have been shared widely and included as part of the package.⁴¹³⁴¹³ Roe {Day212/155:2-12}.

¶74.56 Director Reason said that the training package had been seen by the Commissioner, Deputy Commissioner and the Directors and that, to his recollection, no concerns had been raised about its general content or whether it covered the coroner's recommendations effectively.⁴¹⁴⁴¹⁴ Reason {Day181/9:3-22}. The training package was not subsequently reviewed to ensure that it dealt with them adequately,⁴¹⁵⁴¹⁵ Reason {Day181/11:3-9}. other than by identifying any deficiencies in operational responses identified through routine IMP database reports submitted to the co-ordination board.⁴¹⁶⁴¹⁶ Reason {LFB00067846/28} page 28, paragraph 61; Reason {Day181/20:2}-{Day181/22:1}.

¶74.57 Although a number of senior LFB witnesses regarded the case study as a key element of its response to the Lakanal House fire,⁴¹⁷⁴¹⁷ Reason {Day181/88:18}-{Day181/89:13}, {Day180/177:9}-{Day180/178:6}, {Day181/37:16}-{Day181/38:17}; David Brown {Day187/73:23}-{Day187/75:16}; Cowup {Day195/116:11-20}; Dobson {Day211/6:6-11}, {Day211/11:24}- {Day211/12:4}. it fell far short of what was required. The delay of five years between the fire and the release of the training package emphasises the LFB's failure to identify quickly the important lessons to be learnt from the incident and provide the necessary training as quickly as possible. That failure was compounded by the fact that the training package failed to address the most important aspects of the Lakanal House fire. It was primarily a narrative account of the incident, which limited its value as training for crews. Director Reason said that the package had not been intended for use in isolation, but together with other training packages, although he accepted that it was necessary for officers themselves to find the relevant packages or policies to study.⁴¹⁸⁴¹⁸ Reason {Day181/3:23}-{Day181/5 -18}. Given the nature and potential scale of the dangers revealed by the Lakanal House fire, it was not appropriate to rely on individual officers to take the initiative to that extent. The situation was further worsened by the failure of other LFB training programmes to cover all the coroner's recommendations.

¶74.58 The LFB's knowledge about the risks posed by combustible panels should have been communicated to operational crews through appropriate additions to the training programme in late 2013 after it had become clear from correspondence with DCLG about the meaning of functional requirement B4(1) that the government would not take any steps (at least in the short term) to address the problem. Regrettably, however, that did not happen. There were no relevant changes in training and the information was not adequately communicated to operational crews. When asked about the failure to inform crews about these risks, Commissioner Dobson said they were matters that concerned the Fire Safety and Enforcement arms of the LFB, rather than the operational crews.⁴¹⁹⁴¹⁹ Dobson {Day211/4:16}-{Day211/6:19}; {Day211/26:19}-{Day211/27:14}. That view was both wrong and short-sighted. Although compliance with the Building Regulations was no doubt a primary concern of the Fire Safety and Enforcement departments, the consequences of an extensive failure of compartmentation resulting from the use of combustible materials which allowed fire to spread rapidly across the external wall of a building would directly affect operational crews. They had particular implications for incident commanders implementing a "stay put" strategy that was still regarded within the LFB as underpinning the approach to fighting fires in high-rise buildings at the time of the Grenfell Tower fire.

Conclusions

¶74.59 The Lakanal House fire should have alerted the LFB to the possibility that ineffective compartmentation throughout a high-rise residential block might result in a rapid total failure of the building. LFB witnesses maintained in their evidence to us that the risk of a failure of compartmentation was an important lesson taken from the Lakanal House fire and referred to training initiatives subsequently introduced, including the case study, as having enhanced operational crews' understanding of that risk and how to respond to it.⁴²⁰⁴²⁰ Cowup {Day195/49:1-8}, {Day195/163:5-7}, Dobson {Day211/11:16}-{Day211/12:8}, {Day211/44:15-23}, {Day211/6:6- 11}, Cotton {Day208/178:5-19}. However, that was far from the case. In fact, the important subject of how to identify and respond to a failure of compartmentation remained strikingly absent from LFB training and policy following the Lakanal House fire. It was not mentioned in the revised edition of GRA 3.2 published in 2014, which the LFB was largely responsible for drafting, or in the incident command training that the LFB introduced in response to the coroner's recommendation.

¶74.60 The LFB's response to the Lakanal House fire placed undue reliance on process. Plans were made, boards were established and reviews were commissioned, but the process failed to ensure that the organisation fully understood and acted on the different aspects of its experience at the Lakanal House fire, in particular the danger of relying on compartmentation, the risk of fire spreading across external walls and the importance of being able to handle many fire survival guidance calls simultaneously. The LFB's failure to understand the importance of those matters is illustrated by their omission from the training package. The truth is that the LFB failed to consider in a systematic and rigorous way whether the outcome of the process provided an effective response to the questions raised by the fire.