Chapter 76: Operational planning

Introduction

¶76.1 In his Phase 1 report the chairman found that the information available to the first crews mobilised to attend the Grenfell Tower fire was incomplete and in some respects inaccurate.⁵⁰²⁵⁰² Phase 1 Report Volume IV, paragraph 27.30 He also found that the LFB had failed properly to train its crews in how to obtain information when visiting premises for that purpose and had a narrow understanding of its obligations under section 7(2)(d) of the Fire and Rescue Services Act 2004 (the 2004 Act).⁵⁰³⁵⁰³ Phase 1 Report Volume IV, paragraphs 27.36. He said that the reason for those failures would be investigated in the next phase of the Inquiry. We have therefore examined the LFB's approach to operational planning, with particular reference to fighting fires in high-rise residential buildings.

¶76.2 Section 7(2)(d) of the 2004 Act requires fire and rescue authorities to make arrangements for obtaining information needed for the purpose of extinguishing fires and for protecting life and property in the event of fires in their areas. Traditionally, visits by station-based staff to premises in their areas have been regarded as the primary means of discharging that duty and was the method adopted by the LFB.⁵⁰⁴⁵⁰⁴ Phase 1 Report Volume IV, paragraphs 27.22, 27.24 and 27.37.

¶76.3 Information gathered from visits to premises and other sources was entered on the Operational Risk Database (ORD) which was intended to act as the main source of information for incident commanders and other officers responding to an incident. In his Phase 1 report the chairman considered the entries on the ORD for Grenfell Tower, which indicated that the LFB had failed to obtain relevant information from the manager of the building, the TMO, including information relating to the building's cladding system.⁵⁰⁵⁵⁰⁵ Phase 1 Report Volume IV, paragraphs 27.35 and 27.37. Contrary to the plain meaning of the words of Appendix 1 of PN633, it was not the practice for operational personnel responsible for conducting visits to high-rise premises to consider the full list of items set out there.

¶76.4 In Phase 2 of the Inquiry we have considered what information section 7(2)(d) requires fire and rescue services to gather and how the LFB sought to discharge its duty, including the type of information it thought it needed to obtain, particularly about high-rise residential buildings. We have also considered whether the LFB's policies and practices that were designed to discharge the duty under section 7(2)(d) were appropriate.

Duty to obtain information

¶76.5 The duty to obtain information for the purpose of fighting fires was originally contained in section 1(1)(d) of the Fire Services Act 1947, which was to all intents and purposes the same as section 7(2)(d) of the 2004 Act. Steve McGuirk, the former Chief Executive and County Fire Officer of Greater Manchester Fire and Rescue Service, who was called to give expert evidence on fire-fighting, explained that the duty had originally been interpreted by fire and rescue authorities as requiring the collection of simple information that would be readily and quickly accessible to the first crews attending an incident,⁵⁰⁶⁵⁰⁶ McGuirk {Day190/11:18-23}; {Day190/12:2-11}; {Day190/13:12-23}; {Day190/15:7-24}. and that had remained their approach to discharging the duty under section 7(2)(d) of the 2004 Act.⁵⁰⁷⁵⁰⁷ McGuirk {Day190/14:9}-{Day190/15:2}.

¶76.6 In April 2012, the government issued guidance to fire and rescue services on the collection and management of operational risk information, that is, the information they are required to collect under section 7(2)(d).⁵⁰⁸⁵⁰⁸ {HOM00045364}. It contained a model approach entitled Provision of Operational Risk Information System, or PORIS for short. It was the first substantive national guidance on the management of operational risk information since the 2004 Act had come into force.⁵⁰⁹⁵⁰⁹ McGuirk {Day190/16:7-16}. Mr McGuirk said that PORIS had marked a change in what was expected of fire and rescue authorities because it required a much more sophisticated system for managing information about risks, but he doubted whether it had brought about a widespread change in the way that most fire and rescue authorities went about gathering information. That may have been because the guidance was released with little publicity, but in any event, there has been no monitoring of whether any, and if so, how many, authorities have adopted the model.⁵¹⁰⁵¹⁰ McGuirk {Day190/18:5}-{Day190/19:14}; {Day190/37:7-25}.

¶76.7 The PORIS model involved five steps: (1) review existing information; (2) where necessary, collect additional information by way of a site visit; (3) use that information to assess the risk presented by the particular building or site; (4) determine the appropriate risk management process; (5) provide the relevant information for use by incident commanders in a timely manner. The guidance provided a template "data capture" form, to be used for the collection of information, including information collected during visits to premises.⁵¹¹⁵¹¹ McGuirk {Day190/20:1-8}. It is notable that the form included a section entitled "cladding and roof" and invited the user to select from a number of different alternatives, including "sandwich panel", "metal sheet" and "uPVC".⁵¹²⁵¹² {HOM00045364/85}.

¶76.8 It is immediately apparent when looking at the data capture form (which is almost 20 pages long, extremely broad in scope and in parts very technical) that the guidance issued in 2012 envisaged a process for the collection and management of operational risk information very different from the simple and practical approach that had previously been adopted by fire and rescue authorities. Mr McGuirk described the guidance as prescribing a much more expansive approach which required a significant amount of additional training.⁵¹³⁵¹³ McGuirk {Day190/25:25}-{Day190/26:23}. Following the introduction of PORIS, as Mr McGuirk put it, operational firefighters were intended to become "more rounded risk assessors, capable of assembling and evaluating a much greater range of information."⁵¹⁴⁵¹⁴ McGuirk, Firefighting Report {SMC00000046/15} paragraph 21.

Collection and management of operational risk information by the LFB

¶76.9 The LFB policies for the management of operational risk information were PN800, which applied to all properties, and PN633, which related specifically to high-rise buildings. Appendix 1 of PN633 contained a list of 22 items to be considered by crews during section 7(2)(d) visits.⁵¹⁵⁵¹⁵ {LFB00083849}; {LFB00001256}. In addition, PN784 governed the sharing of information relevant to operational planning between the LFB's Fire Safety department and fire stations.

¶76.10 In broad terms, the version of PN800 in force in June 2017 mirrored the five stages of the PORIS model. In particular, it required crews to carry out a premises risk assessment based on the risks identified during section 7(2)(d) visits using the form in Appendix 1 of the policy. That resulted in the premises achieving a certain risk score, which determined the frequency of further visits, the need for exercises on the premises and whether a tactical plan was required. Grenfell Tower had been placed in the medium- to low-risk category by the risk assessment carried out at the last visit before 14 June 2017. As a result, it qualified for at least one visit by a local crew every three years and a tactical plan. An exercise on the premises was not required unless the local station manager thought it necessary.⁵¹⁶⁵¹⁶ {LFB00003596}. No tactical plan was ever put in place for Grenfell Tower.⁵¹⁷⁵¹⁷ Phase 1 Report Volume IV, paragraph 27.30.

¶76.11 PN800 recognised the role of the LFB's Fire Safety department in the collection, management and analysis of operational risk information. In particular, the policy noted that one of the ways in which premises giving rise to certain hazards or risks were identified was by notification from the Fire Safety department. PN800 also directed crews to consider whether the risk assessment process required specialist knowledge, including knowledge available from the Fire Safety Regulation department.⁵¹⁸⁵¹⁸ {LFB00083849/4}; {LFB00083849/7} paragraph 7.20.

¶76.12 PN784 governed the way in which information was to be shared between the Fire Safety team and operational crews.⁵¹⁹⁵¹⁹ {LFB00012734}. In short, PN784 set out a procedure under which officers in the Fire Safety department were to communicate to station-based personnel information likely to be relevant when planning for operational incidents, and vice versa. Such information was to be communicated in a prescribed form and, on receipt, the station manager or Fire Safety team leader was to decide what action was appropriate, which might include a joint visit.

¶76.14 The picture recorded in the report of 12 May 2015 was consistent with the evidence of AC Daly. He said that on the whole, the flow of information between the Fire Safety department and the fire stations did not work well and was patchy, in the sense that it worked better in some areas than others.⁵²³⁵²³ Daly {Day183/46:10}-{Day183/47:11}; {Day184/107:17}-{Day184/108:7}. Both Commissioner Dobson and Commissioner Roe agreed with that assessment.⁵²⁴⁵²⁴ Dobson {Day211/210:14-19}; Roe {Day213/122:10-19}. The LFB's Director of Operations, Dave Brown, said that the LFB had put measures in place to address the shortcomings in the system which had led to improvements.⁵²⁵⁵²⁵ Brown {Day187/38:8-14}; {Day187/40:8-14}. Whatever measures had been implemented, they were ineffective, because the sharing of information between the Fire Safety department and fire stations remained unsatisfactory at the time of the Grenfell Tower fire. AC Daly was a frank and reliable witness, who had much closer contact with the day-to-day management of the Fire Safety department than Director Brown. On this point, we prefer AC Daly's evidence. Indeed, Grenfell Tower was a tragic illustration of the failings in the LFB's arrangements for sharing information. The North Kensington crews who carried out section 7(2)(d) visits to the tower did not obtain from the TMO information relating to the building's cladding system or even basic floor plans showing the layout and numbers of individual flats. Under the LFB's own policies and procedures that information should have been obtained by the local crews.

Application to high-rise buildings

¶76.15 Neither PN800 nor PN784 provided any direction or guidance on the management of operational risk information relating specifically to high-rise buildings, which at the time of the Grenfell Tower fire was contained in PN633, the LFB's policy on firefighting in high‑rise buildings. PN633 was considered in some detail in Phase 1 of the Inquiry. Appendix 1 of PN633 transposed national guidance on firefighting in high-rise buildings, contained in GRA 3.2, into the LFB's local policy, insofar as the collection of operational risk information was concerned. Specifically, the LFB's list of items to be considered during visits to high-rise buildings broadly corresponded to that prescribed by GRA 3.2, apart from the omission from Appendix 1 of any reference to cladding.⁵²⁶⁵²⁶ {LFB00001255/18}.

¶76.16 Mr McGuirk thought that it would take an operational crew at least two hours properly to consider all 22 items listed in Appendix 1 of PN633.⁵²⁷⁵²⁷ The full list is set out in the Phase 1 Report Volume IV, paragraph 27.23. He disagreed with Commissioner Cotton's characterisation of the list as being, in parts at least, unrealistic or incorrect. In his view, it was necessary and appropriate for crews in London to be directed to consider all 22 items as well as the information required by the PORIS model. He did not think it was beyond the capacity of station-based operational crews to undertake risk assessments of that scope and level of detail, provided they were given appropriate training. In his opinion, the practical simplicity of the former approach to management of operational risk information can still be maintained, thereby preserving the need for essential information to be readily available to the first responding crews, if measures are taken to filter the information properly as it is provided to those on the incident ground.⁵²⁸⁵²⁸ McGuirk, Firefighting Report {SMC00000046/33-34} paragraphs 79 and 80.

¶76.17 The LFB's policy documents did not make it clear whether all high-rise buildings should be the subject of section 7(2)(d) visits and have an entry on the operational risk database or only some. AC Brown said that ideally every high-rise building in London would be visited and subject to a risk assessment, a view with which Commissioner Dobson agreed.⁵²⁹⁵²⁹ Brown {Day211/197:22}-{Day211/198:8}. However, that might or might not have led to their being recorded on the ORD, since PN800 prescribed a minimum threshold risk score for that purpose.⁵³⁰⁵³⁰ Brown {Day186/54:15-20}. PN800 required all premises that scored 150 or above on the risk assessment to be recorded on the ORD {LFB00083849}. AC Brown accepted that he had faced considerable difficulties in achieving that ideal during his time in the brigade, not least because the LFB did not know, and had no obvious means of finding out, how many high-rise buildings there were in London and where they were situated.⁵³¹⁵³¹ Brown {Day186/55:4-22}; {Day186/101:5-15}.

¶76.18 The figures that have been provided to us indicate that the LFB was a long way from achieving AC Brown's ideal. The Lakanal Assurance Report, a review carried out by the LFB in August 2018 of the action taken in response to the Lakanal House fire, recorded that in October 2017 approximately 1,700 high-rise buildings had been subject to a risk assessment out of a total of about 6,900 such buildings in London.⁵³²⁵³² {LFB00004801/28}. The LFB has since confirmed that the total number is in fact about 8,500.⁵³³⁵³³ Roe {Day213/125:8-20}.

¶76.19 The reason why such a low number of high-rise buildings appeared on the ORD might have been the apparent confusion within the LFB over whether crews were expected to visit all high-rise buildings on their ground and, if not, which ones they were expected to visit. AC Brown sent an email to station managers in April 2009 directing them to ensure that crews visited all the high-rise buildings on their ground every year.⁵³⁴⁵³⁴ {LFB00032161}. His recollection was that, at that time, he had felt that that was not an unreasonable expectation, because he had not been quite sure how many there were. At a later stage, however, when the magnitude of the task became more apparent, a more risk-based approach was adopted.⁵³⁵⁵³⁵ Brown {Day186/59:16-25}.

¶76.20 It appears that AC Brown's instructions still stood in 2010, when PN633 underwent one of the several reviews that were carried out following the Lakanal House fire. Peter Cowup, who was then a DAC in the LFB's Operational Policy department and was leading the review of PN633, sent an email on 1 August 2010 to various senior officers within the LFB noting that the feasibility of crews visiting all high-rise buildings on their station's ground required further consideration, because of the size of the task, especially for stations in central London.⁵³⁶⁵³⁶ {LFB00082695}.

¶76.21 In November 2011, the LFB published Operational News 20, which contained an article on high-rise firefighting. In that article personnel were told that any high-rise buildings which posed a particular risk should be the subject of section 7(2)(d) visits.⁵³⁷⁵³⁷ {LFB00047224}. AC Brown denied that the article reflected a departure from his earlier direction that all high-rise buildings should be visited. He said that the article had been intended to refer to the fact that high-rise buildings would be subject to regular section 7(2)(d) visits in future only if they were considered to pose a particular risk after they had been subject to an initial risk assessment.⁵³⁸⁵³⁸ Brown {Day186/69:19}-{Day186/70:1}. We do not accept that. The text of the article in Operational News is clear and is not qualified in the way he suggested. The article is a straightforward guide for station-based crews on the LFB's statutory obligations in relation to high-rise buildings. We think that it illustrates the lack of a consistent approach to whether section 7(2)(d) of the 2004 Act required the LFB to visit all high-rise buildings or only those deemed on some undefined basis to present a high risk.

¶76.22 As has been noted, Appendix 1 of PN633 listed 22 items which crews were required to consider during section 7(2)(d) visits to high-rise buildings. Mr McGuirk and Commissioner Cotton expressed different views about the practicability of complying with Appendix 1 to the letter. From around 2012 until his retirement in March 2017, Director Brown had ultimate oversight of the LFB's fire stations and responsibility for discharging its obligations under section 7(2)(d).⁵³⁹⁵³⁹ Brown {Day186/7:17}-{Day186/18:1}. His evidence was therefore of particular help in understanding the nature of the information the LFB expected its operational crews to gather.

¶76.23 AC Brown expected crews to use the list in Appendix 1 to PN633 as an aide memoire and to consider the items where practicable. He accepted that that was not reflected in its language, which required crews to ensure that they were familiar with the various items contained in the list.⁵⁴⁰⁵⁴⁰ Brown {Day186/29:17}-{Day186/32:4}. However, he did not think that station-based crews had the technical knowledge to look in depth at factors that might give rise to breaches of compartmentation, despite that being one of the items mentioned in the list. He said that, leaving aside obvious problems, such as an open vent in a communal stairwell, it was beyond the skill and knowledge of operational crews to identify defects likely to have that effect.⁵⁴¹⁵⁴¹ Brown {Day186/32:15}-{Day186/33:7}. Similarly, when asked whether he would expect crews to identify features of a building that might promote the rapid or abnormal spread of fire (another item in the list) AC Brown said that that was at the extreme of the knowledge to be expected of a firefighter and that the LFB would rely on a member of the Fire Safety department to identify features of that kind.⁵⁴²⁵⁴² Brown {Day186/37:13}-{Day186/38:3}. Commissioner Dobson was similarly sceptical. He said that some of the items in the list would have required very specialist training to enable crews to carry them out properly. He doubted the likely benefit of such training in any event.⁵⁴³⁵⁴³ Dobson {Day211/208:15-24}.

¶76.24 AC Brown did not expect crews to look at a building's cladding system during a section 7(2)(d) visit or to decide whether it should be taken into account in the risk assessment.⁵⁴⁴⁵⁴⁴ Brown {Day186/40:11-21}. Again, he thought that was beyond the ability and training of operational personnel.⁵⁴⁵⁵⁴⁵ Brown {Day186/43:13-19}. There was no discussion internally following the Lakanal House fire about whether to direct crews to consider cladding systems,⁵⁴⁶⁵⁴⁶ Brown {Day186/46:25}-{Day186/47:4}. despite the fact that Commissioner Dobson had been sufficiently concerned about unsuitable panels to write to Sir Ken Knight on the subject in December 2009.⁵⁴⁷⁵⁴⁷ {LFB00104291}. AC Brown told us that other steps had been taken to deal with that, which did not involve operational firefighters in that level of detail.⁵⁴⁸⁵⁴⁸ Brown {Day186/45:6-22}. Nor was any consideration given to requiring crews to collect information about cladding systems of high-rise buildings following the fire at Shepherd's Court in August 2016.⁵⁴⁹⁵⁴⁹ Brown {Day186/47:6-10}.

¶76.25 The lack of any advice or direction to crews about how to carry out visits to high-rise premises for the purposes of section 7(2)(d) is clear from the operational risk information training materials that were provided to the Inquiry, which were limited to a single, interactive computer-based training programme produced by Babcock in around May 2013.⁵⁵⁰⁵⁵⁰ Stills from the programme are at {LFB00123288}; the accompanying trainer guide dated May 2013, is at {BAB00000058}. AC Brown confirmed that that was the first time crews had received formal training on how to conduct such visits,⁵⁵¹⁵⁵¹ Brown {Day186/146:17-24}. and we are satisfied that it was the only time. The package was not directed specifically to high-rise buildings and did not contain any reference to PN633. Although it did provide some commentary on what to look for on such a visit, that commentary did not address the risk of fire spreading beyond the compartment of origin or the existence of features of construction that might promote the rapid or abnormal spread of fire, both of which are included in the list contained in Appendix 1. Perhaps unsurprisingly, the training did not ensure that crews understood the purpose of their visits, nor what information they were expected to obtain and record. That is apparent from the deficiencies in the ORD entry for Grenfell Tower, considered in detail in the Phase 1 report.⁵⁵²⁵⁵² Phase 1 Report Volume IV, paragraph 27.30. Although AC Brown and DAC George sought to suggest otherwise,⁵⁵³⁵⁵³ Brown {Day186/202:22-25}; George {Day205/186:2-9}. Commissioner Roe confirmed that such deficiencies were not confined to Grenfell Tower, as might be expected.⁵⁵⁴⁵⁵⁴ Roe {Day213/108:6-22}. He told us that a review of the entries on the ORD carried out after the Grenfell Tower fire had revealed a range of inconsistencies, poor information and a misunderstanding of risk.⁵⁵⁵⁵⁵⁵ Smith {Day203/108:11-22}.

¶76.26 The LFB's failure, following the Lakanal House fire, to instruct operational crews visiting premises pursuant to section 7(2)(d) to consider the potential for widespread compartmentation failure and the rapid or abnormal spread of fire was significant. It is not sufficient for it to point to measures that might have been taken by the Fire Safety department if the concerns of senior officers had been brought to its attention. Operational crews were not provided with the direction or training to enable them to identify the matters that should have been reported and largely disregarded the system for sharing such information.

The LFB's response to PORIS

¶76.27 The publication of PORIS in April 2012 provided another opportunity for the LFB to review and consider the effectiveness of its processes for the management of operational risk information. On 27 February 2013, a report by Susan Ellison-Bunce, Head of Strategy and Performance, was submitted to the Corporate Management Board, which considered the new guidance and the extent to which the LFB complied with it.⁵⁵⁶⁵⁵⁶ {LFB00091785}. She concluded that the existing processes were robust and largely complied with national guidance and that it was not necessary or practicable to make significant adjustments to the current arrangements.⁵⁵⁷⁵⁵⁷ {LFB00091785/20}.

¶76.28 Ms Ellison-Bunce also noted that the national guidance referred to the importance of periodic audits as a means of monitoring whether operational risk management systems had been properly implemented and maintained and were effective in meeting their objectives. She found that there were inconsistencies in the approaches taken by stations to what was included on the ORD and that the quality of the work done in obtaining and using information varied. Ms Ellison-Bunce therefore recommended that the Head of Operational Assurance (then AC Cotton) review how stations identified sites and buildings that might present a risk and whether they adopted an approach consistent with PN800.⁵⁵⁸⁵⁵⁸ {LFB00091785/15}. AC Brown told us that that review had not been carried out.⁵⁵⁹⁵⁵⁹ Brown {Day186/150:5}-{Day186/153:10}.

The rule 43 recommendations on section 7(2)(d) visits

¶76.29 In her Rule 43 letter to the LFB the coroner recommended that it review its procedures for sharing information obtained pursuant to section 7(2)(d) with crews both within the station in question and at other local stations.⁵⁶⁰⁵⁶⁰ {LFB00032158/2}. In response the LFB created a regime for inspecting what Commissioner Dobson had referred to in his letter to the coroner of 23 May 2013 as "high priority" buildings, with a view to increasing the number of premises in respect of which information was available on the ORD.⁵⁶¹⁵⁶¹ {LFB00042089/4}. The term "high priority" did not appear in either PN800 or PN633. AC Brown told us that he did not know where it had come from and thought it had caused some unnecessary confusion.⁵⁶²⁵⁶² Brown {Day186/175:16}-{Day186/176:3}. The purpose of the new regime was to identify buildings that had not been the subject of a risk assessment but should have been.⁵⁶³⁵⁶³ Brown {Day186/176:13-22}. It was not specifically aimed at high-rise buildings, but they were regarded as a priority.⁵⁶⁴⁵⁶⁴ Brown {Day186/179:5-9}. AC Brown wanted to create an inspection regime that resulted in more entries on the ORD and was concentrated on those that presented higher risks.⁵⁶⁵⁵⁶⁵ Brown {Day186/176:13}-{Day186/177:2}; {Day186/182:6-23}.

¶76.30 In November 2013 AC Brown asked DAC Tom George to set up the new regime, but he immediately delegated the task to GM John Elwell.⁵⁶⁶⁵⁶⁶ George {LFB00032823/17}, page 17, paragraph 69. DAC George provided GM Elwell with little guidance on what was required, apart from telling him that he needed to strengthen the inspection programme and increase the number of entries on the ORD.⁵⁶⁷⁵⁶⁷ {LFB00042252/2}.

¶76.31 On 11 December 2013, GM Elwell produced a careful and considered report for DAC George and AC Brown,⁵⁶⁸⁵⁶⁸ {LFB00032825}. in which he identified the following questions that he thought were raised by the concern that there were too few entries on the ORD:

¶"a) Is the existing guidance (PN800) fit for purpose to achieve the desired outcomes?

b) What other Brigade data could be deployed to identify relevant premises for inclusion on the ORD. c) Are the 7000 we have all relevant and in compliance with the guidance in PN800? d) Which premises are 'missing' from the ORD given the guidance in PN800? e) What is the capacity of a station/watch in terms of the number of ORD entries that can be effectively entered and revisited with the existing guidance. A pertinent point, given the disparity of the numbers, risk and types of premises on different stations ground. f) Is the quality of existing ORD entries providing data to underpin safe systems of work? g) Are our staff competent to carry out the 72d visits and enter meaningful data and professional tactical plans? h) What are the existing Performance Evaluation Tools to monitor performance? i) What Service Standard is in place to Quality Assure the relevant extant policies?"

¶76.32 The questions identified by GM Elwell demonstrated a perceptive understanding of the difficulties that beset the LFB's systems for the collection and management of operational risk information. Indeed, they foreshadowed many of the concerns that have been raised during this Inquiry, in particular, about the capacity of individual stations to manage the number of premises on their grounds effectively, the quality of the existing entries on the ORD and the competence of operational staff to carry out visits and record relevant information.

¶76.33 When he came to deliver his report⁵⁶⁹⁵⁶⁹ {LFB00032825}. and recommendations GM Elwell concentrated on the following: a. The importance of the direct involvement of operational crews and their managers in

meetings and workshops to reinforce the provisions of PN800 and make clear what it expected of them. In particular, he warned that the then current practice of announcing new policies by email would not be adequate to explain effectively the requirements of PN800, a revised edition of which was due to be published soon after the report.

¶b. The need for a feasibility study to be carried out in relation to the use of existing data held by the LFB for the purpose of risk assessments, including the information recorded on the "Farynor" database, which held information collected on fire safety inspections. (The Farynor database had preceded and was separate from the ORD, but crews had access to it).⁵⁷⁰⁵⁷⁰ Brown {Day187/35:11}-{Day187/36:5}.

¶c. The need to review the disparity in the number and nature of the risks across different station grounds and the development of a means of determining the optimal number of ORD entries for stations with a large number of high risk properties.

¶d. The need for further training to be provided to all personnel with a role in the process of creating the ORD to ensure that they had the necessary skills.

¶e. The need to be able to measure the number and quality of the entries on the ORD to determine whether they complied with the requirements of PN800.

¶76.34 AC Brown's response to the report was that, although it was interesting and helpful, it did not amount to the creation of a high priority inspection regime.⁵⁷¹⁵⁷¹ Brown {Day186/190:21}-{Day186/191:7}. He accepted that the report had raised some significant broader concerns about the adequacy of the LFB's existing arrangements, but he told us that some of the recommendations had either been implemented already, were in the course of being implemented, or were within GM Elwell's power to implement. He thought that one or two were very aspirational and, although desirable in principle, would not work in practice.⁵⁷²⁵⁷² Brown {Day186/191:8-18}; {Day187/4:6-11}.

¶76.35 AC Brown thought that discussions between managers about section 7(2)(d) visits were an established part of normal business and that nothing further needed to be done in that respect.⁵⁷³⁵⁷³ Brown {Day186/192:9-15}; Brown {LFB00123276/7} pages 6-7, paragraph 19. He said that work had already been done by the LFB's Information Management department to link information obtained from previous section 7(2)(d) visits with data available from other internal sources, including the Fire Safety department. He did not think that there could be a review of the varying levels of risk across different stations because the LFB did not have the necessary information. It could therefore not determine an optimal number of entries on the ORD for any individual station; all it could do was to direct crews that in due course all premises should be inspected to determine their suitability for inclusion on the database. He was satisfied that training on section 7(2) (d) visits had recently been given to crews (meaning, the training package distributed in May 2013)⁵⁷⁴⁵⁷⁴ {LFB00123288}; {BAB00000058}. and considered that the LFB needed first to assess the results of that training in order to determine whether more was required. When asked about the need to monitor the quality as well as the quantity of the entries on the ORD, he said that it was incredibly difficult to measure quality in any meaningful way.⁵⁷⁵⁵⁷⁵ Brown {LFB00123276/8} page 8, paragraph 24.

¶76.36 We are unable to accept that AC Brown carefully considered each of GM Elwell's recommendations when the report was presented to him in late 2013. The weight of the evidence shows that he was concentrating on the introduction of an inspection regime aimed at "high priority" buildings, however defined. We think that he rejected the recommendations because they were not directly related to the creation of such a regime. In so doing, he did not properly reflect on the very real concerns that had been raised by GM Elwell.

¶76.37 We gained the strong impression that AC Brown did not wish to become involved in considering the complexities of an inspection regime, a problem which deserved more careful consideration than he was willing or able to give it. If the letter and spirit of the coroner's recommendation were to be satisfied and more effective inspection arrangements introduced, the matters raised by GM Elwell required proper consideration. AC Brown failed to give them that consideration and, as far as we can see, there was no good reason for that. If GM Elwell's recommendations had been implemented, they could have gone some way towards remedying the deficiencies in the LFB's arrangements for gathering and managing operational risk information.

¶76.38 On 22 January 2014, following AC Brown's effective rejection of GM Elwell's report, DAC George compiled a list of different types of property for inspection in order of priority that he proposed should be given to station managers and borough commanders.⁵⁷⁶⁵⁷⁶ {LFB00083388}. High‑rise residential buildings of six floors and above appeared on the list second only to sites such as industrial plants of a kind which present major accident hazards. A list of that kind was exactly what AC Brown wanted.⁵⁷⁷⁵⁷⁷ Brown {Day187/9:19}-{Day187/10:3}. DAC George said, however, that in his view and that of his colleagues, a satisfactory banding system was not entirely achievable and that he had reservations about such a simplistic approach.⁵⁷⁸⁵⁷⁸ George {LFB00032823/20} page 20, paragraphs 75-76; George {Day206/17:1-14}. In particular, he was concerned that the system was more concerned with numbers than quality and that it would be virtually impossible for crews to carry out meaningful inspections of such a large number of premises.⁵⁷⁹⁵⁷⁹ George {LFB00083884/19} page 19-20, paragraph 74. AC Brown did not agree with DAC George's reservations⁵⁸⁰⁵⁸⁰ Brown {Day187/12:13-16}; {Day187/13:7-13}. and on 24 May 2014 he sent an email to all operational crews directing them to have regard to the priority banding system when conducting section 7(2)(d) visits.⁵⁸¹⁵⁸¹ {LFB00032160}; Brown {Day187/15:2-6}; {Day187/15:18-25}.

¶76.39 The priority banding system was never formally incorporated into any policy,⁵⁸²⁵⁸² Brown {Day187/18:21-24}. but DAC George told us that he had monitored its implementation by watch managers through regular meetings with the borough commanders beneath him in the LFB's organisational structure. AC Brown had no further involvement in the inspection regime and did not ask to be provided with any further information about its success in increasing the number of entries on the ORD or its progress generally.⁵⁸³⁵⁸³ George {Day206/29:15}-{Day206/30:20}; {Day206/32:1-13}.

Communications

¶76.40 The references in PN800 to factors liable to affect communications were confined to circumstances likely to be encountered underground or in other places which may have alternative communications infrastructure, including fixed radio repeaters. However, the list of matters in Appendix 1 to PN633 on high-rise firefighting that were to be considered on visits to high-rise buildings did include potential problems with communications.⁵⁸⁴⁵⁸⁴ {LFB00001256/19}.

¶76.41 The evidence given in Phase 2 about the practical application of those policies was inconsistent and uncertain. In particular, senior officers did not clearly understand whether there was a need to test the performance of radios when visiting a high-rise building.⁵⁸⁵⁵⁸⁵ Documents created during and immediately after the Lakanal House inquests give conflicting views on whether radio testing formed a standard part of every s.7(2)(d) visit: {LFB00036836} and {LFB00098636/2}. PN633 contained no guidance for crews on how to identify potential difficulties with communications or how to test radio reception reliably.⁵⁸⁶⁵⁸⁶ Brown {Day187/26:4}-{Day187/32:4}. Although WM Ricketts from North Kensington fire station tested the transmission of radio signals between the basement and the ground floor using his handheld UHF radio during a visit to Grenfell Tower immediately before the fire, that could have given only a limited indication of the performance of radios in the tower under operational conditions.⁵⁸⁷⁵⁸⁷ Johnson, Communications Report {CWJ00000119/110} paragraphs 5.4.4-5.4.5; Johnson {Day189/153:15}- {Day189/154:24}. Professor Johnson suggested that a more detailed test, using validated procedures, may be needed in structures known to pose a particular risk of deteriorating communications.⁵⁸⁸⁵⁸⁸ Johnson {Day189/155:2}-{Day189/156:1}; {Day189/156:13}-{Day189/157:16}.