Chapter 75: Existing sources of information

¶75.1 By the summer of 2016, the Lakanal House fire was not the only source of information available to the LFB about the risk of rapid external fire spread and the consequent loss of compartmentation associated with the use of modern building materials and the problems to which that can give rise. In this chapter, we consider other sources of information about the dangers posed by the use of combustible materials in external walls and the experience of the LFB at other fires in high-rise buildings in London.

¶75.2 First, we consider a fire that occurred in a building called Madingley in Kingston-on‑Thames in July 2010 and certain correspondence between the LFB and DCLG about the effect of functional requirement B4 that took place between February 2011 and October 2013. We then consider in this context fires in high-rise buildings abroad, to which we referred in Chapter 11. Finally, we consider two fires that broke out in high-rise residential buildings in London, Adair Tower in October 2015 and Shepherd's Court in August 2016. Both incidents illustrated the LFB's practical approach, following the Lakanal House fire, to the risks posed by combustible cladding (in particular, the prospect of a complete failure of compartmentation), the need to evacuate parts of a high-rise building and how best to carry out an evacuation.

The Madingley fire

¶75.3 Not long after Commissioner Dobson's exchange of correspondence with DCLG at the end of 2009, another incident occurred in London involving the spread of fire through combustible materials in a building's façade. The fire at Madingley, a 17-storey residential building in Kingston-upon-Thames, occurred on 12 July 2010. It started in a flat on floor 12, spread rapidly through a plastic rainwater pipe system to flats on floors 13, 14 and 15 and thence to the roof of the building. Smoke entered the building's escape stairs on floor 15. Twenty fire appliances attended the incident. About 80 people evacuated the building; no‑one was injured.⁴²¹⁴²¹ {LFB00028515}.

¶75.4 Tests carried out by both Bureau Veritas and the LFB established that the rainwater pipe system was the principal means by which the fire had spread, but other materials forming part of the balconies and the edge of the roof were also examined. It was found that glass‑reinforced plastic fascia panels and polystyrene insulation on the balconies were easily ignited and, once ignited, continued to burn and spread flames rapidly, producing large amounts of black smoke. A castellated roof fascia panel was found to behave in the same way. Bureau Veritas concluded that those elements could contribute significantly to the overall intensity of a fire and its combustion products.⁴²²⁴²² Bureau Veritas report {LFB00028515/91-94}; LFB report {LFB00028515/95-102}.

¶75.5 Messages passing between some of those in the LFB who were investigating the Madingley fire show that they considered the possibility that the other three blocks on the estate could contain similar materials and discussed whether it would be appropriate to implement an "early evacuation" strategy rather than "defend in place" if there were another fire.⁴²³⁴²³ {LFB00028515/64}. The evidence we have seen, however, suggests that the change was not made and that crews were not given any warning about those risks.⁴²⁴⁴²⁴ {LFB00028515/117-122}.

Correspondence about the meaning of functional requirement B4(1)

¶75.6 Between February 2011 and October 2013, the LFB entered into correspondence with DCLG in an attempt to obtain clarification of the effect of functional requirement B4(1) (the requirement that the external walls of a building shall adequately resist the spread of fire over the walls and from one building to another, having regard to the height, use and position of the building). Following the receipt of advice from a retired building surveyor, the Commissioner had become concerned that the language used did not make it clear that the ability adequately to resist the spread of fire over external walls was a requirement in its own right. Indeed, the person from whom the Commissioner had taken advice thought it was not. As the LFB recognised at the time, that was an incorrect interpretation, but it suggested that there might be widespread misunderstanding about the effect of functional requirement B4(1) that was shared even by some building control officers. That was potentially a matter of national importance.

¶75.7 The attempt to obtain a definitive interpretation of the regulations failed because DCLG was unwilling to provide formal clarification of the effect of functional requirement B4(1), but the correspondence clearly shows that senior officers in the LFB were aware that there was considerable uncertainty in the construction industry about its meaning and that there was a potentially widespread failure to comply with the requirements of the Building Regulations in relation to the external walls of high-rise buildings. They expected the problems to increase in the absence of effective regulatory intervention.⁴²⁵⁴²⁵ Dobson {Day211/26:11-18}. The LFB did all it reasonably could to persuade the government that action was required, but its concerns were not properly addressed. Nonetheless, the episode had served to draw the attention of the LFB to the uncertainty in the construction industry surrounding the meaning of functional requirement B4(1), and provided it with an opportunity to consider what, if any, changes were required to existing training, operational policies and procedures.

¶75.8 The LFB's knowledge of 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 that the government would not take any steps (at least in the short term) to address the problems identified in the correspondence. 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 those risks, Commissioner Dobson said that they were matters that concerned the Fire Safety and Enforcement arms of the LFB, rather than the operational crews.⁴²⁶⁴²⁶ Dobson {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 following a "stay put" strategy, which was still regarded within the LFB as underpinning the approach to fighting fires in high-rise residential buildings.

International fires

¶75.9 In Chapter 11 we have referred to the information available about fires in high‑rise buildings in other countries, all of which involved to a greater or lesser degree the spread of fire across external walls. Before the Grenfell Tower fire occurred, the LFB had no system for recording fires of that kind, for investigating why or how they had occurred, or for considering whether they contained any lessons for fire prevention or high-rise firefighting in London. The main reason for that omission appears to have been a widely‑held assumption that fires of that kind could not occur in this country because the Building Regulations did not allow buildings to be constructed in a way that would allow the spread of fire over the external walls. There was also a prevalent view that the UK's regulatory regime was superior to, and more robust than, those in other countries.⁴²⁷⁴²⁷ Dexter {Day179/95:21}-{Day179/97:19}; Reason {Day182/101:2}-{Day182/102:25}; Daly {Day183/117:22}- {Day183/136:9}; {Day183/163:8}-{Day183/164:8}; Cotton {Day209/231:10}-{Day209/232:11}; Cotton {Day209/233:11- 21}; Dobson {Day211/33:4}-{Day211/36:1}. Two examples demonstrate the shortcomings of this approach to the gathering and analysis of information from fires outside this country.

The Lacrosse fire, Melbourne, Australia (November 2014)

¶75.10 The Lacrosse fire caused the authorities to carry out an audit of Melbourne's high-rise buildings. In March 2016, the LFB was provided with the results of that audit, which revealed that 51% of the buildings surveyed did not comply with the regulations. AC Daly was asked whether that ought to have alerted the LFB to the possibility that the position in London might be similar. It was a relevant question, because, as we have pointed out, the LFB's reliance on the existence of a robust regulatory system in the UK necessarily depended on compliance with it. His response was that it was likely that the question had been raised within the LFB at the time, but that there was no evidence that there were buildings in London that used external wall cladding that did not comply with the Building Regulations.⁴²⁸⁴²⁸ Daly {Day183/170:12}-{Day183/178:17}. The explanation was unsatisfactory, first, because there is no evidence that the question had actually been considered in that way, and secondly, because the purpose of any investigation would have been to discover whether there had been a widespread failure to comply with the regulatory requirements. In our view, the unexpectedly high rate of non-compliance found in Melbourne was a compelling reason for the LFB to consider whether the same problem existed in London.

The Address fire, Dubai, UAE (December 2015)

¶75.11 Information about the fire at the Address building in Dubai reached senior officers of the LFB through DAC Graham Ellis who sent an email to two of his LFB colleagues containing a link to an article about flammable polyurethane and aluminium cladding involved in a fire in Dubai.⁴²⁹⁴²⁹ {LFB00024217}. He copied his message to AC Cotton in her capacity as Head of Operational Assurance. The article said that the fire had resurrected fears about the widespread use of highly combustible materials on skyscrapers across the UAE. It also said that a fire safety expert had estimated that up to 70% of Dubai's high-rise buildings could be clad in polyurethane and aluminium composite cladding, notwithstanding the requirement in the UAE that buildings over 30 metres in height be constructed from non-combustible materials. Towards the end of the article the author referred to the regulatory position in Britain, which he said did not permit any surface spread of flame.⁴³⁰⁴³⁰ {INQ00014890}.

¶75.12 Responding to the email from DAC Ellis, GM Biles made a flippant comment about paragraph 12.7 of Approved Document B, which provided by way of guidance that insulation products and filler materials should be of limited combustibility. AC Cotton replied to his comment, also in flippant terms. Neither paragraph 12.7 nor the broader requirements of Approved Document B had been mentioned in the body of the article, but they had been mentioned in a comment made by an online user who drew attention to the distinction between a Class 0 surface and a combustible core and asserted that there were large schemes still being constructed in the UK for which similar panels were being incorrectly specified due to a fundamental misunderstanding of the regulations.

¶75.13 AC Cotton said that she had not read the comments below the main body of the article,⁴³¹⁴³¹ Cotton {Day210/9:12-13}. but the reference to clause 12.7 in his comment shows that, at the very least, GM Biles had. We think it surprising that none of those who received the email thought it necessary to draw the attention of the Fire Safety department to the article or the online comment, given that the comment suggested that there was a fundamental misunderstanding within the construction industry about the requirements of the Building Regulations relating to materials used in external walls. The exchange also revealed a failure by senior officers adequately to probe and question information they did not fully understand. Most importantly, the LFB should have been alert to the risk that there might be many buildings in London with dangerous cladding, but it was too complacent to discover the existence and extent of any problem in London before it was too late.

NHBC seminar – 'Facades to Tall Buildings'

¶75.14 On 7 July 2016 members of the LFB's Fire Safety department attended a seminar organised by the NHBC entitled "Facades to Tall Buildings". One presentation contained images of fires in high-rise buildings both in the UK and abroad, including the Address Tower fire in 2015 and the Tamweel Tower fire in 2012, both in Dubai, and the Garnock Court fire in Glasgow in 1999.⁴³²⁴³² {LFB00032916/2-4}. It also contained diagrams depicting different mechanisms of external flame spread taken from BR135 Fire performance of external thermal insulation for walls of multi-storey buildings (3rd ed., 2013) and relevant extracts from Approved Document B and Building Control Alliance Technical Guidance Note 18.⁴³³⁴³³ {LFB00032916/5-9}. The content of the seminar was subsequently used to create the LFB's own presentation entitled "Tall Buildings Facades".

¶75.15 AC Daly said that the conference had been seen as providing reassurance about conditions and regulations in this country.⁴³⁴⁴³⁴ Daly {Day183/135:12}-{Day183/136:9}; {Day183/145:16}-{Day183/146:13}. However, we draw exactly the opposite conclusion. First, in the course of the seminar the NHBC warned about the dangers of highly combustible polythene-cored ACM products, the omission of cavity barriers around openings, unrealistic assumptions about the fire resistance of glazing and confusion between the fire resistance of a wall assembly and fire spread across or within it.⁴³⁵⁴³⁵ {LFB00032892/10-11}. Secondly, the Building Control Alliance, in a presentation on demonstrating compliance with the Building Regulations, had separately sounded a warning about a number of matters, including the absence of any tests using lightweight metal claddings, desktop assessments by fire engineers being based on opinion rather than fact, and the substitution of materials.⁴³⁶⁴³⁶ {LFB00032891/14}. Thirdly, Brian Martin's presentation on regulatory requirements contained a diagram taken from BR135 which showed how combustible cladding systems could contribute to the spread of flame and the risk of secondary fires.⁴³⁷⁴³⁷ {LFB00032895/6}. Fourthly, the BRE explained the mechanisms of external fire spread involving combustible materials and stated that the BS 8414 test method was being used in the same or a substantially similar way in the UAE, Australia and China.⁴³⁸⁴³⁸ {LFB00032922/21-22}.

¶75.16 The LFB was well aware of those warnings. It should, therefore, have been aware of the importance of understanding the risk of rapid external fire spread in buildings in London. The LFB's own "Tall Buildings Facades" presentation⁴³⁹⁴³⁹ {LFB00032916}. It was produced in draft in July 2016 and finalised in October 2016 after the fire at Shepherd Court. carried a number of relevant warnings. First, it warned that although it was a general principle that the external envelope of a building should not contribute to the spread of fire, new construction materials and methods of construction were being used in facades with a limited understanding of their behaviour when exposed to fire. The same slide warned that such materials could affect the way that fires develop and spread in a building. Secondly, it warned of the importance of the facade's not contributing significantly to the spread of fire. Thirdly, it identified combustible materials in the facade as likely to lead to the spread of fire. Fourthly, it reproduced the diagrams in BR135 depicting the mechanisms of external fire spread. Finally, it concluded that the construction of the facade of Shepherd's Court might have contributed to the fire spread. There was, therefore, nothing in the various presentations to justify an unqualified assumption that the risk of rapid external fire spread was, in some way, restricted to methods of construction used abroad.

¶75.17 The evidence from fires abroad and the warnings and concerns expressed about building methods used in this country partly reflected, but certainly confirmed, the LFB's knowledge of, and longstanding anxiety about, a widespread failure to comply with the Building Regulations in London and, in particular, about modern construction materials which caused or permitted the unusual spread of smoke and fire. That knowledge and those worries pre-dated the Lakanal House fire in July 2009 and were reinforced by the Shepherd's Court fire in August 2016, discussed below.

¶75.18 Commissioner Cotton said she was unaware that anyone in the LFB had ever brought the risk of failure to comply with the Building Regulations to the attention of senior officers.⁴⁴⁰⁴⁴⁰ Cotton {Day209/233:22}-{Day209/234:5}. She told us that neither she nor the Operational Assurance department had been made aware that the LFB knew about problems caused by poor compartmentation (and the implications for a "stay put" strategy) until April 2017, when a letter raising the question had been drafted by the LFB's Fire Safety department and sent in her name (as Commissioner) to Gavin Barwell MP and Brandon Lewis MP (Minister for Housing and Minister for Policing and the Fire Service respectively).⁴⁴¹⁴⁴¹ Cotton {Day210/3:18}-{Day210/4:17}; {Day210/19:4}-{Day210/28:17}. She said that the Operational Assurance department had never been asked to consider the risks resulting from failure to comply with the Building Regulations or the spread of fire resulting from an inappropriate choice of materials, which had never been brought to its attention.⁴⁴²⁴⁴² Cotton {Day210/5:3}-{Day210/6:13}.

¶75.19 It is clear to us that communications between the different departments of the LFB were very limited and that as a result there was a significant failure to ensure that important information, in this case information about threats to the built environment, was shared with departments which really needed to receive it. The Fire Safety department should have worked much more closely with the Operational Assurance department to investigate significant fires in other countries and to understand whether there was anything important to be learnt from them. Instead, there is no evidence that either of those departments, or indeed any other department, used them as a means of improving their understanding of the risks associated with modern and refurbished buildings and their ability to fight fires in high-rise buildings. That reflected both a failure of organisation and management and a failure on the part of individual officers to display the breadth of vision to be expected of them.

The Adair Tower and Shepherd's Court fires

¶75.20 Two other fires in high-rise residential buildings occurred in London following the Lakanal House fire, both of which gave rise to challenges similar to those that had been encountered at that fire and were to be encountered again at the Grenfell Tower fire. The first was the fire at Adair Tower; the second was the fire at Shepherd's Court.

The Adair Tower fire

¶75.21 Adair Tower is a 14-floor residential building. On 31 October 2015, a fire was started by a lighted firework being put through the letterbox of a flat on the third floor. When the first crews arrived, they reported a fully developed fire that had spread into the adjoining lobby. Neighbouring flats were affected by smoke and heat, as were the main stairwell and communal lobbies on higher floors. There were no self-closing devices on the doors of the flats, which made it easier for smoke to spread. 19 pump appliances attended the fire.⁴⁴³⁴⁴³ {LFB00001708}.

¶75.22 A considerable number of calls were made by residents of Adair Tower to the control room during the course of the incident, including calls during which fire survival guidance was given. The LFB's records were not consistent in recording the number of fire survival guidance calls.⁴⁴⁴⁴⁴⁴ Contemporaneous documents referred variously to 9 and 24 fire survival guidance calls: {LFB00001711}; {LFB00031757}. Up to six fire survival guidance calls (depending on how they were characterised) were received between 08.54 and 09.08, together with 15 other calls.⁴⁴⁵⁴⁴⁵ {LFB00035092/5}; FSG database {LFB00031757}; Smith {Day202/201:1-20}. In any event, the total number of fire survival guidance calls made during the Adair Tower fire exceeded the five received during the Lakanal House fire.⁴⁴⁶⁴⁴⁶ {HOM00001124}. The incident commander, GM Anthony Biles, who had 34 years of operational experience, said that it was the highest number of fire survival guidance calls that he had dealt with in his career.⁴⁴⁷⁴⁴⁷ {MET00080605/13}. Fifty residents were helped to escape the building, either by firefighters or by control room officers (CROs) who provided advice and guidance.⁴⁴⁸⁴⁴⁸ {LFB00001708/2}; {LFB00035109}.

¶75.23 When GM Biles arrived at the incident ground, he realised that many people were trapped and needed to be rescued, or believed that they did, so he obtained additional crews with extended duration breathing apparatus (EDBA) to conduct search and rescue operations on higher floors and hand over residents they had rescued to firefighters wearing standard breathing apparatus on the lower floors. GM Biles did not formally revoke the "stay put" strategy, but he briefed crews to clear the building.⁴⁴⁹⁴⁴⁹ Biles {MET00080605/7-8} pages 7-8.

¶75.24 The incident monitoring process report recorded that there had been good handling of a large volume of fire survival guidance information with finite resources. There was no reference to the evacuation of residents or the "stay put" strategy.⁴⁵⁰⁴⁵⁰ {MET00080621}.

The Shepherd's Court fire

¶75.25 Shepherd's Court is a 20-floor residential building in Shepherd's Bush. On 19 August 2016, a fire started in a faulty appliance in a flat on floor 7. It spread to floors 8, 9, 10 and 11 through external facade panels and entered some of the flats on those floors through open windows. The block's single stairwell had a good level of compartmentation and individual flats had good fire doors with self-closing devices. Twenty appliances attended the fire, which was ultimately extinguished.⁴⁵¹⁴⁵¹ {LFB00118245}; {LFB00000084}.

¶75.26 SM Charles Hanks was the second incident commander, having assumed command about 34 minutes after the first crews had arrived.⁴⁵²⁴⁵² {LFB00060951/8}. He remained in command for about ten minutes until GM Richard Ogden arrived.⁴⁵³⁴⁵³ Hanks {LFB00032724/2} page 2, paragraph 5. During that ten-minute period he saw that the fire had spread to the floor above the flat of origin, which he recognised indicated a possible failure of compartmentation. Soon after, SM Hanks was told that a third floor had become involved in the fire. He became concerned that there was a risk that the fire might spread further externally and also a risk that it might spread in the interior of the building.⁴⁵⁴⁴⁵⁴ Hanks {LFB00032724/2-3} pages 2-3, paragraph 6. He described the spread of fire as "exceptional", although there had been very little spread of smoke and flame in the interior and the stairwell had not been affected.⁴⁵⁵⁴⁵⁵ Hanks {LFB00032724/3} page 3, paragraph 7.

¶75.27 Once SM Hanks had become aware that three floors had become involved in the fire, he decided that he needed to ensure that the flats immediately above the fire were empty and that any occupants were moved to safety when possible. (He said that, if necessary, he would have carried out a controlled evacuation of the occupants from the flats on the 9 floors immediately above because the fire was spreading vertically but not sideways.) At the same time, he directed crews to begin a systematic search from the top of the building, moving downwards to obtain information about the conditions within the building rather than to carry out search and rescue operations or to evacuate flats on those higher floors. His strategy was not intended to undermine the "stay put" policy, which in his view was maintained throughout, but was in his view a sensible precaution for one or two flats when conditions allowed, given that fires can occasionally jump a compartment boundary.⁴⁵⁶⁴⁵⁶ Hanks {LFB00032724/4-5} pages 4-5, paragraph 8. The LFB's Fire Investigation report records that approximately 50 people had been evacuated from the building.⁴⁵⁷⁴⁵⁷ {LFB00000084/8} paragraph 4.26.

¶75.28 The LFB has rightly accepted that, before the Grenfell Tower fire, it had failed to train its incident commanders to understand when and how to carry out an evacuation of a high‑rise residential building with a "stay put" strategy in the absence of an existing plan.⁴⁵⁸⁴⁵⁸ Roe {LFB00060655/9} page 9, paragraph 21; Roe {LFB00083834/7-8} pages 7-8, paragraph 28; Closing statement for Modules 5 and 6 {LFB00123737/14} paragraph 35; {LFB00123737/35} paragraph 93. It was a failing which had the most serious consequences for the residents of Grenfell Tower on the night of 14 June 2017.⁴⁵⁹⁴⁵⁹ Phase 1 Report Volume IV {INQ00014817/87} paragraph 27.3.

¶75.29 It must also be acknowledged, however, that the LFB was not alone in this failing. At the time of the Grenfell Tower fire there was no national operational guidance on how to evacuate a residential high-rise building⁴⁶⁰⁴⁶⁰ McGuirk Report {SMC00000046/35} paragraph 83. and it does not appear that any other fire and rescue service in the United Kingdom had included in their operational policies or training any guidance on the practical aspects of carrying out an evacuation, beyond saying that it should be considered, as in PN63. On that basis, we agree with DAC Cowup's description of evacuation as a blind spot for the LFB. There is also some evidence to suggest that it may be a blind spot for other fire and rescue services, although we have not heard evidence about current firefighting practice outside London and Kent.⁴⁶¹⁴⁶¹ Cowup {Day195/63:20}-{Day195/67:21}.

¶75.30 Nonetheless, the operational responses to the Adair Tower and Shepherd's Court fires demonstrate that, although the LFB was not training its commanders on the evacuation of high-rise residential buildings, nor providing for it in its policies, it contained officers who were capable of carrying out some form of successful evacuations in high-rise residential buildings and, when circumstances required, did so. Commissioner Roe referred to incidents within his own knowledge where there had been a partial failure of compartmentation and where the incident commander had made a decision to evacuate the floors above and below the fire, while the rest of the residents remained in their flats. Commissioner Dobson also agreed that evacuation was not an unusual occurrence and that firefighters were well acquainted with evacuating all sorts of buildings, including high-rise buildings.⁴⁶²⁴⁶² Dobson {Day211/127:10-12}. DAC Cowup similarly told us that evacuation was a fairly routine and intuitive process, though he accepted that before the Grenfell Tower fire the LFB had not understood the need to provide firefighters with specific guidance on it.⁴⁶³⁴⁶³ Cowup {Day195/66:1-22}.

¶75.31 It is important to note that evacuation is not necessarily inconsistent with a "stay put" strategy. If residents are being adversely affected by heat, fire or smoke, their evacuation is entirely consistent with such a strategy. However, the evacuation of flats which are not adversely affected by heat, fire or smoke does involve a revocation, at least in part, of a "stay put" strategy. There was no reference to the "stay put" strategy or to the partial evacuation of residents in the IMP reports on either the Adair Tower or the Shepherd's Court fires,⁴⁶⁴⁴⁶⁴ {MET00080621}; {LFB00120998}. but we are satisfied that in practice some incident commanders have carried out emergency evacuations, including the evacuation of flats not adversely affected by smoke or fire, of some kinds of residential high-rise buildings with "stay put" strategies without recording the fact. It is not possible to say with confidence how frequently they have done so, but Adair Tower and Shepherd's Court do not appear to have been isolated incidents. The incident commanders at both fires appear to have acted intuitively, without notifying the control room, and no one appears to have regarded their actions as particularly significant. That suggests that the approach taken at both those incidents was not out of the ordinary. Indeed, Commissioner Roe referred to incidents within his own knowledge where there had been a partial failure of compartmentation and where the incident commander had made a decision to evacuate the floors above and below the fire, while the rest of the residents remained in their flats.⁴⁶⁵⁴⁶⁵ Roe {Day213/147:15-23}.

¶75.32 The evidence suggests that before the Grenfell Tower fire evacuations of high-rise residential buildings had been partial rather than total.⁴⁶⁶⁴⁶⁶ Roe {Day213/147:5-23}. (At any rate, we have not been provided with any evidence of a total evacuation of a residential high-rise building in London or elsewhere in the United Kingdom.) As was the case at Adair Tower and Shepherd's Court, such evacuations were probably carried out without discussion with the control room and perhaps without the commander necessarily considering whether the "stay put" strategy had been revoked. In such instances, it was the individual commander who made the decision based on his or her own judgement, deploying such practical strategies for the implementation of the evacuation as he or she saw fit. Before the Grenfell Tower fire, it was, ultimately, a matter of chance whether the officer acting as incident commander at any given time had sufficient experience and confidence to evacuate a high‑rise residential building, despite the absence of any training on when and how to do so.

¶75.33 None of this undermines the conclusion in the Phase 1 report that "stay put" had become an article of faith for the LFB.⁴⁶⁷⁴⁶⁷ Phase 1 Report Volume IV {INQ00014817/108} paragraphs 28.53 and 28.54. Institutionally, it was indeed so and the response at Grenfell Tower reflected that fact. However, the evidence heard in Phase 2 identified an inconsistency of approach and whether the incident commander considered evacuation owed nothing to established policy.

¶75.34 Another aspect of the Shepherd's Court fire that prefigured the hazards encountered at Grenfell Tower was the use of combustible facade panels, in that case containing polystyrene insulation. On his arrival at the incident AC Daly, who was the most senior incident commander to attend the fire, saw fire spreading over the walls, which he thought was unusual because he would not have expected exterior panels to support combustion.⁴⁶⁸⁴⁶⁸ Daly {MET00077774/4}; Daly {Day183/206:11-18}. He thought it was the same phenomenon as had been observed at the Lakanal House fire.⁴⁶⁹⁴⁶⁹ Daly {Day183/205:17}-{Day183/206:13}. AC Daly consulted SM James Flin, who was in attendance as a fire safety officer and was also a fire engineer, and the two of them agreed that it was necessary to find out why the spandrel panels appeared to have spread the fire.⁴⁷⁰⁴⁷⁰ Daly {Day183/210:24}-{Day183/211:20}.

¶75.35 On 29 August 2016, sample panels were duly sent to Bureau Veritas for testing which was witnessed by personnel from the Fire Engineering team in the LFB's Fire Safety department.⁴⁷¹⁴⁷¹ {LFB00052135/6}. The panels contained a blue polystyrene foam insulation mounted on a plywood board. One of the samples had a steel facing sheet; the steel sheet of the other had become detached during the fire, exposing the foam beneath. The sample panels were exposed to three flame tests. In the case of the panel without a steel facing sheet, the blue foam was rapidly destroyed, creating flaming droplets and sustaining burning even after the removal of the flame source. One of the tests had to be stopped due to concerns about the height of the flames. In its report of 30 November 2016 Bureau Veritas confirmed that the panels were likely to have assisted the fire in spreading up the outside of Shepherd's Court.⁴⁷²⁴⁷² {LFB00000091/2-4} paragraphs 3.5 and 3.6.

¶75.36 On receipt of those findings, Charles Elie-Romeyer, a fire engineer in the LFB's Fire Safety department who had witnessed the tests, revised the "Tall Buildings Facades" presentation to reflect the Shepherd's Court incident so that it could be used at a training day for senior fire safety officers.⁴⁷³⁴⁷³ Green {LFB00032917/1-2} pages 1-2, paragraphs 3-5; Green {LFB00032917/5} page 5, paragraphs 23-26. In the section on the Shepherd's Court fire added by Mr Elie-Romeyer, the results of the Bureau Veritas tests were set out, including photographs of the burning sample panels together with the observation that the facade might have contributed to the spread of fire.⁴⁷⁴⁴⁷⁴ {LFB00032916/15-20}.

¶75.37 AC Daly confirmed that the presentation had not been shared with anyone outside the Fire Safety Department, and, in particular, that it had not been shared with operational crews because of what he described as the very technical nature of the information relating to quite a complex area which operational personnel could not be expected to grasp or understand.⁴⁷⁵⁴⁷⁵ Daly {Day183/138:24}-{Day183/139:11}; {Day183/142:9}-{Day183/143:16}. The Commissioner accepted that the presentation reflected the Fire Safety department's knowledge of the potential for modern construction materials to promote the rapid spread of fire, and that there had been a failure to ensure that that information was communicated to the rest of the LFB, including operational staff.⁴⁷⁶⁴⁷⁶ Closing statement in Modules 5 and 6 {LFB00123737/19} paragraphs 44 and 45.

The Parkin-Coates report: November 2015

¶75.38 The Fire Safety Department's continuing concern about compartmentation had previously been reflected in a report by Ms Adreena Parkin-Coates entitled Compartmentation Issues within the Built Environment published on 26 November 2015. Ms Parkin-Coates was a qualified fire engineer and a business support manager in the Fire Safety Department.⁴⁷⁷⁴⁷⁷ {LFB00025654}; Daly {Day184/85:3-5}. Like the later Jack report of August 2016, the Parkin-Coates report referred to the importance of adequate compartmentation in defining a building's evacuation strategy. It also asserted that instances of inadequate compartmentation were widespread. In her summary of the report Ms Parkin-Coates noted that the success of many evacuation strategies, particularly "stay put" strategies, depended on adequate compartmentation, but that fire safety officers were becoming increasingly aware of defects in fire-stopping in new and refurbished buildings. She concluded that defects in compartmentation were widespread due to poor workmanship or a lack of oversight by building control bodies and contractors and that an overall strategy to address them was needed.⁴⁷⁸⁴⁷⁸ {LFB00025654/1}.

¶75.39 In her report Ms Parkin-Coates accepted a view expressed by others that there was an endemic problem of sub-standard fire-stopping.⁴⁷⁹⁴⁷⁹ {LFB00025654/2} paragraph 1. AC Daly thought that the use of the word "endemic" was likely to reflect the frequency with which defects in compartmentation had been identified in the pool of buildings that had been found not to comply with the Building Regulations during fire safety audits conducted by the LFB. (He said that about 70% of premises were found to be broadly compliant.) He accepted, however, that within that smaller pool of buildings, defects in compartmentation were identified reasonably regularly. He did not agree that sub-standard compartmentation was endemic across the built environment as a whole.⁴⁸⁰⁴⁸⁰ Daly {Day184/88:2-14}.

¶75.40 Ms Parkin-Coates also referred to the Bush House fire in 2007, which had prompted a meeting with the government and other interested parties in 2010, and to the NHBC training initiatives that had been implemented in association with the Chief Fire Officers Association in 2011.⁴⁸¹⁴⁸¹ {LFB00025654/3-4}. She also referred to and annexed a separate report entitled Structural Fire Safety Failures – Quarterly/Annual Reporting dated March 2015, which was provided to the Performance Management Board with her report because it was said to identify a number of other fires at which structural defects had been found.⁴⁸²⁴⁸² {LFB00025654/10}. The quarterly report for the period April to December 2014 recorded that 25 fires had occurred, three of which had exhibited possible defects in structural fire safety features that might have contributed to the development of the fire. All three of those fires, which included the fire at Holcroft House, had occurred in residential blocks of flats.⁴⁸³⁴⁸³ {LFB00025654/11-12}. As noted earlier, the report recorded that some of the structural defects affecting fire safety identified at those incidents ought to have been recorded on the relevant building's ORD entry, but had not been.⁴⁸⁴⁴⁸⁴ {LFB00025654/12} paragraphs 11 and 13.

¶75.41 AC Daly told us that the Parkin-Coates report, with all its appended reports, had been waiting for his attention when he took over as Head of Fire Safety in March 2016.⁴⁸⁵⁴⁸⁵ Daly {Day184/92:12-13}. He told us that the material had given him cause for concern and that it had indicated that there were systemic issues that needed to be addressed.⁴⁸⁶⁴⁸⁶ Daly {Day184/94:9-13}. He accepted that his concerns suggested that there were things that operational firefighters as well as the Fire Safety department needed to learn and accepted that the LFB had not always gained as much from the work of the Fire Safety department as it could have, in particular by involving operational crews in its thinking.⁴⁸⁷⁴⁸⁷ Daly {Day184/94:22}-{Day184/95:20}. It is notable that, in the revised version of the Parkin‑Coates report prepared in December 2016 for presentation to the Corporate Management Board, the range of suggestions for action related to the Fire Safety department and Fire Safety personnel alone. There was no suggestion that operational personnel should be involved in any way in the measures proposed for remedying inadequate compartmentation.⁴⁸⁸⁴⁸⁸ {LFB00000155/6} paragraph 37. We accept that it was not a deliberate omission,⁴⁸⁹⁴⁸⁹ Daly {Day184/112:13-24}. but it is significant for what it tells us about the nature and extent of the collaboration between the fire safety and operational sides of the LFB.

The Jack report: August 2016

¶75.42 In late 2016, at the time that the Fire Safety department was discussing its concerns about the misinterpretation of functional requirement B4, it was also doing work on compartmentation in residential blocks of flats.⁴⁹⁰⁴⁹⁰ Jack {LFB00120308/18} page 18, paragraph 61; {LFB00120296}. As it had in relation to the exterior walls of such properties, the department continued to question whether its enforcement powers under the Fire Safety Order extended to the fire-resisting walls between individual flats. That was not a new issue. It had featured in discussions between the LFB and DCLG in 2012, which had culminated in Louise Upton's advice of 6 February 2013 that the Fire Safety Order did not extend to the external walls of a building.⁴⁹¹⁴⁹¹ {LFB00032153}. In August 2016, Andrew Jack produced a report entitled Fire Resisting Compartmentation – Flats (the Jack report) that was presented to the Principal Management Board, a departmental management board chaired by AC Daly and attended by the heads of the different teams in Fire Safety.⁴⁹²⁴⁹² {LFB00120301}; Daly {Day184/65:14-22}. The report refers to the "Performance Management Board", which Dan Daly clarified in his evidence was likely to be a typographical error: {Day184/67:2-15}. The Jack report described the benefits of taking enforcement action, where necessary, in respect of inadequate compartmentation, even though its power in law to do so was considered to be unclear. It noted that compartmentation between flats was of vital importance to prevent the spread of fire through a building containing multiple dwellings and was essential if an evacuation strategy based on "defend in place" was to be employed.⁴⁹³⁴⁹³ {LFB00120301/2}. ("Defend in place" is essentially the same as a "stay put" strategy.)

¶75.43 Mr Jack observed that fire risk assessments rarely consider compartmentation in areas of the building away from the means of escape and that there was therefore scant factual basis to justify the use of a "stay put" emergency plan.⁴⁹⁴⁴⁹⁴ {LFB00120301/3}. That reflected the fact that a "stay put" strategy for any building is fundamentally dependent on compartmentation being effective and that, in order to rely on "stay put" as a strategy, the building's compartmentation must be sound. It also follows that, from an operational perspective, it cannot be assumed that compartmentation will in fact be effective.

¶75.44 The Jack report contained examples of buildings whose compartmentation had been found to be inadequate, including Lakanal House, and noted that more examples were likely to be discovered as a result of fire risk assessments.⁴⁹⁵⁴⁹⁵ {LFB00120301/3}; {LFB00120301/8}. AC Daly said that a great deal of the LFB's enforcement work concerned breaches of compartmentation and that his own operational experience had been that it was often possible to find products of combustion where you would not expect them.⁴⁹⁶⁴⁹⁶ Daly {Day184/74:1}-{Day184/75:1}. However, he did not accept that the LFB had reason to think that inadequate compartmentation was a widespread problem.⁴⁹⁷⁴⁹⁷ Daly {Day184/78:19-24}. It is also clear that no thought was given by the LFB at that stage to the potential combination of inadequate compartmentation and combustible facade systems, even though the report was being written while Bureau Veritas was carrying out tests on the panels taken from Shepherd's Court.⁴⁹⁸⁴⁹⁸ Daly {Day184/76:10}-{Day184/77:4}. The Fire Safety department did not take the opportunity to raise its concerns about inadequate compartmentation in the letter it sent to chief executives on 6 April 2017. This might have been due to the fact that compartmentation had been effective at Shepherd's Court, thereby keeping the single staircase clear of smoke and fire and enabling the partial evacuation of residents.

¶75.45 On 3 April 2017, Commissioner Cotton wrote to the then Gavin Barwell MP, Minister of State for Housing and Planning and Minister for London, requesting a meeting to discuss the LFB's concern about inadequate compartmentation in residential blocks of flats.⁴⁹⁹⁴⁹⁹ {CLG10009016}. In her letter she pointed out that effective compartmentation is essential to the operation of the "stay put" policy that applies to most residential buildings. She expressed concern that since the beginning of 2017 the LFB had identified, on average, at least one residential property (or development) a month in London that had significant defects in compartmentation and that there were many other cases that had not come to the LFB's attention.

¶75.46 Commissioner Cotton told us that the letter had been drafted by AC Daly and that she had not been aware of the problems to which it referred before he had spoken to her about the draft.⁵⁰⁰⁵⁰⁰ Cotton {Day210/28:5-17}. She did not take any steps to check what training was being provided to operational personnel about the risks posed by failures of compartmentation or their effect on a building's "stay put" strategy.⁵⁰¹⁵⁰¹ Cotton {Day210/26:21}-{Day210/27:15}.

Conclusions

¶75.47 By the end of 2016, the LFB as an organisation was well aware of the dangers posed by some kinds of modern construction materials and techniques and of the particular dangers presented by various kinds of combustible materials, mainly those used for their insulating properties. That included sandwich panels, insulation boards made of organic materials and, most importantly for present purposes, external panels containing organic materials intended to provide rigidity as well as insulation, all of which had the propensity to lead to a loss of compartmentation in a major fire. Regrettably, however, that knowledge was almost entirely confined to the Fire Safety department and was not shared with those who were responsible for operations. As a result, those who were deployed to fight fires were not trained to deal with situations which could become catastrophic both for them and, in the case of residential buildings, their occupants. In particular, incident commanders were not sufficiently aware that a "stay put" strategy may not be reliable in all circumstances and that evacuation may be necessary.