Chapter 77: High-rise firefighting: policy and guidance

Introduction

¶77.1 The Generic Risk Assessments were published by the Chief Fire and Rescue Adviser in conjunction with DCLG to provide operational guidance to fire and rescue authorities. In his Phase 1 report the chairman described the purpose of Generic Risk Assessment (GRA) 3.2, which contained the national guidance on firefighting in high-rise buildings, as being to assist fire and rescue services in drawing up their own assessments of risk to meet their statutory obligations under the relevant Health and Safety at Work legislation.⁵⁸⁹⁵⁸⁹ Phase 1 Report Volume IV paragraph 27.1. The provisions of GRA 3.2 that are most relevant to the hazards encountered at Grenfell Tower were identified in the Phase 1 report.⁵⁹⁰⁵⁹⁰ Phase 1 Report Volume IV paragraph 27.3. In summary, they relate to planning, training and competence, and the provision of fire survival guidance.

¶77.2 Individual fire and rescue services are obliged to have regard to national guidance when carrying out the risk assessments which underpin their operational policies.⁵⁹¹⁵⁹¹ {LFB00001255/7}. The LFB's policy on high-rise firefighting was PN633; the version published in June 2015 was in force at the time of the Grenfell Tower fire.⁵⁹²⁵⁹² {LFB00001256}.

The review of Generic Risk Assessment 3.2

¶77.3 The second version of GRA 3.2 had been published in 2008, and in 2010 a review of the full GRA series was commissioned by DCLG and the Chief Fire and Rescue Adviser.⁵⁹³⁵⁹³ {LFB00032783/6} paragraph 2.2.1. Although DCLG in conjunction with the Chief Fire and Rescue Adviser had final editorial control of the series as a whole, DCLG retained particular responsibility for the contents of GRA 3.2.⁵⁹⁴⁵⁹⁴ Cowup {Day195/24:4-8}; Knight {Day245/146:10}-{Day245/148:11}. The review process began in 2010 and culminated in a revised version published in 2014.⁵⁹⁵⁵⁹⁵ {HOM00002128}. DCLG delegated the management of the review to Surrey Fire and Rescue Service under the terms of a memorandum of understanding,⁵⁹⁶⁵⁹⁶ {HOM00050078}. but oversaw the process through a strategic management board established for the purpose.

¶77.4 The review of GRA 3.2 was given priority over the work on other Generic Risk Assessments because it was thought that important insights had been gained into fighting fires in high-rise buildings as a result of the experience at Lakanal House.⁵⁹⁷⁵⁹⁷ Cowup {Day195/22:23}-{Day195/23:6}; {Day195/39:20}-{Day195/40:25}. In March 2011 the LFB was appointed to lead the work on GRA 3.2; no other fire and rescue service was involved in the drafting.⁵⁹⁸⁵⁹⁸ Cowup {Day195/20:9-19}. The LFB was seen as the appropriate organisation to take on that role because much of the learning that needed to be incorporated into the guidance had been derived from the Lakanal House fire.⁵⁹⁹⁵⁹⁹ Cowup {Day195/41:16-24}. The close involvement of the LFB in the revision of GRA 3.2 gave it a unique opportunity to gain a deep understanding of the risks to which firefighters and members of the public may be exposed in such situations, particularly in buildings that have been constructed using novel products and modern materials and methods of construction. It is therefore worth considering in a little detail the way in which the revision of GRA 3.2 proceeded and the extent to which the guidance it contained was reflected in the revision of the LFB's own policy on fighting fires in high-rise buildings.

¶77.5 Within the LFB, DAC Cowup was given primary responsibility for producing the revised version of GRA 3.2 with support from members of the Operational Policy department.⁶⁰⁰⁶⁰⁰ Cowup {Day195/91:4-16}. In December 2011, he and his team produced a draft revised version of GRA 3.2,⁶⁰¹⁶⁰¹ Cowup {LFB00119849/37} page 37, paragraph 82. which was then the subject of a regional and national consultation until September 2012.⁶⁰²⁶⁰² Cowup {LFB00119849/51} page 51, paragraph 115. The draft was revised during the course of that process to reflect some of the responses that had already been received. At that stage, DAC Cowup was confident that it fully reflected the lessons to be learnt from the Lakanal House fire, subject to the findings of the inquests which were due to start in January 2013.⁶⁰³⁶⁰³ Cowup {Day195/133:20}-{Day195/134:3}.

¶77.6 The draft produced during the consultation period contained new sections on evacuation and handling fire survival guidance calls. It contained the same direction to the incident commander to follow any evacuation plan devised as part of the occupier's fire risk assessment,⁶⁰⁴⁶⁰⁴ {LFB00033886/25}. but there was no express reference to the potential need to carry out an evacuation of a residential building with a "stay put" strategy. In particular, the oblique reference to the "stay put" principle did not accurately reflect the national guidance that residents are usually safest remaining in their property unless affected by fire, heat or smoke (whatever the source).⁶⁰⁵⁶⁰⁵ {LFB00033886/25}; {HOM00001124/4}; {LFB00001257/2} paragraph 2.2. There was also no reference to the need to re-evaluate the advice being given to callers during the course of an incident or to the possibility that "stay put" advice might have to be reversed.

¶77.7 DAC Cowup did not accept that he and his team had failed to consider the potential need to revoke "stay put" advice during the course of an incident at a residential high-rise building. On the contrary, he said that they had recognised that it was one of the lessons of the Lakanal House fire. Although he accepted that the draft was not as explicit as it might have been, he thought that people would have understood that to be necessary, having seen the reference to the need to change the evacuation strategy if and when the situation made it appropriate.⁶⁰⁶⁶⁰⁶ Cowup {Day195/113:4-18}.

¶77.8 Following the Lakanal House inquests, DAC Cowup was provided with copies of the coroner's rule 43 letters to the LFB and DCLG, which contained recommendations relating to section 7(2)(d) visits and incident command training. He examined them to ensure that all the points raised in the letters had been covered in the draft revision of GRA 3.2.⁶⁰⁷⁶⁰⁷ Cowup {Day195/182:20-25}. That exercise resulted in further changes to the text, but he did not think that any substantial amendments were required.⁶⁰⁸⁶⁰⁸ Cowup {Day195/187:7-19}; {LFB00102462}.

¶77.9 The section relating to handling fire survival guidance calls was changed, however, by the addition of a direction to re-evaluate the caller's situation from time to time to ensure that the balance of risk between leaving the building and remaining in place was reconsidered as circumstances changed.⁶⁰⁹⁶⁰⁹ {LFB00102462/2}. Those amendments had in fact been suggested by GM Michael Curran, in an email sent to DAC Cowup on 18 March 2013 {LFB00090754}. An amendment to that effect was ultimately included in the published version of GRA 3.2 and was also incorporated into the edition of PN633 published in 2015.⁶¹⁰⁶¹⁰ {LFB00001255/20}; {LFB00001256/14}. The oblique reference to the "stay put" principle was also changed so that it was consistent with the advice contained in national guidance and PN790,⁶¹¹⁶¹¹ {LFB00102462/3}. but no reference was made to the potential need to carry out an evacuation of a high-rise residential building with a "stay put" strategy.

¶77.10 In his response to the coroner's rule 43 letter to his department, the Secretary of State for Communities and Local Government had given a clear undertaking that the revised version of GRA 3.2 would include advice to incident commanders to help them make decisions on evacuation if it became clear during an incident that a "stay put" strategy was no longer tenable.⁶¹²⁶¹² {HOM00047743/2}. DAC Cowup could not recall having seen the Secretary of State's letter.⁶¹³⁶¹³ Cowup {Day195/191:3}-{Day195/192:22}. None of the witnesses who gave evidence to the Inquiry, including those who had worked for DCLG at the time, was able to explain why that was so, despite the letter's obvious relevance to the work on GRA 3.2.

¶77.11 After the Lakanal House inquests ended in March 2013, DCLG officials became involved in the review of GRA 3.2 at what was intended to be the final stage of the preparation of the revised version for publication. Their involvement led to the incorporation of much of the significant new content, including provisions on the need for an evacuation plan and for incident commanders to be able to evacuate buildings with "stay put" strategies.

¶77.12 On 19 June 2013, representatives of the LFB and DCLG met to put the finishing touches to the draft. No one raised any concerns about the text.⁶¹⁴⁶¹⁴ Cowup {Day195/195:18-23}. The draft GRA 3.2 was sent by Les Britzman, who was part of the Chief Fire and Rescue Adviser's team, to Louise Upton, Peter Holland, Brian Martin, Dawn Eastmead, and others within DCLG, on 9 May 2013 {CLG00001921/2}. Following that meeting, however, the draft was reviewed by other officials within DCLG and significant comments were made by Louise Upton, the Head of Fire Safety Policy. In her evidence, Ms Upton said that she had previously known nothing about the review of GRA 3.2, apart from the commitment made in the Secretary of State's letter and having occasionally received various versions of the draft.⁶¹⁵⁶¹⁵ Upton {Day248/61:22-24}; {Day248/100:4-7}. Possibly as a result of her distance from the subject matter, Ms Upton drew attention to significant defects in the treatment of the "stay put" principle and other important aspects of firefighting in high-rise buildings. In an internal email sent to a number of her colleagues on 1 July 2013 she concentrated on the extent to which the document satisfied the Secretary of State's undertaking that the revised version of GRA 3.2 would include advice to incident commanders to help them make decisions about evacuation.⁶¹⁶⁶¹⁶ {CLG00000624}. In a later internal email sent on 29 July 2013 she expressed the view that a more fundamental review of the document was required. She referred to the work done by the LFB since the Lakanal House fire to revise its own operational guidance and considered it odd that the revised draft GRA 3.2 did not appear to reflect the lessons learnt by the LFB as a result of that fire.⁶¹⁷⁶¹⁷ {CLG10005807}. In saying that, she clearly thought that the LFB had given consideration to the potential need to evacuate a high-rise residential building.⁶¹⁸⁶¹⁸ Upton {Day248/85:3-19}.

¶77.13 Another meeting took place on 30 July 2013 to discuss Louise Upton's concerns. It was attended by DAC Cowup and Philip Morton from the LFB, Les Britzman (a member of the Chief Fire and Rescue Adviser's team) and Anthony Maude of DCLG and Leigh Brinton, an employee of Surrey Fire and Rescue Service, who was also involved in the review of GRA 3.2.⁶¹⁹⁶¹⁹ Cowup {Day196/10:11-16}; {Day195/151:19}-{Day195/152:6}. Louise Upton did not attend the meeting because she did not consider that she could contribute on matters relating to operational firefighting. She believed that her concerns would be voiced by Les Britzman.⁶²⁰⁶²⁰ Upton {Day248/86:3-15}.

¶77.14 At the meeting Mr Britzman led the discussion, which concentrated on the treatment of the "stay put" principle.⁶²¹⁶²¹ Cowup {Day196/12:1-11}. According to DAC Cowup, that was the first time that questions of that kind had been raised by DCLG and he had been deeply frustrated by the fact that substantive changes were being proposed at such a late stage.⁶²²⁶²² Cowup {Day196/12:15-25}; {Day196/13:11-20}. Nonetheless, his understanding was that the changes were minor rather than fundamental; DCLG did not tell him that he needed to start again.⁶²³⁶²³ Cowup {Day196/14:2-19}. He said that he had not become aware of DCLG's concern that the draft did not meet the Secretary of State's commitment to the coroner until he was preparing to give evidence.⁶²⁴⁶²⁴ Cowup {Day196/86:22}-{Day196/87:3}. Although the point may not have been made to DAC Cowup with the same clarity as it had been made in Ms Upton's emails, the correspondence following the meeting on 30 July 2013 made clear the department's desire for greater clarity about, and greater emphasis on, the advice to incident commanders about evacuation in order to fulfil the commitment given by the Secretary of State to the coroner.⁶²⁵⁶²⁵ {LFB00102486/2}.

¶77.15 Following the meeting on 30 July 2013, DAC Cowup and his team made further changes to the draft⁶²⁶⁶²⁶ {LFB00052471}. by adding passages on the need to re-evaluate "stay put" advice during the course of an incident and to change it if circumstances made that necessary (both points that had been identified by DAC Cowup in his response to the coroner's rule 43 letters).⁶²⁷⁶²⁷ {LFB00034198/29}; {LFB00057988}. However, the draft still did not mention the need for incident commanders to understand when to carry out an evacuation of a building with a "stay put" strategy or to the need for there to be an evacuation plan if a "stay put" strategy became untenable.

¶77.16 Notwithstanding those revisions, DCLG continued to have misgivings about the draft. On 15 October 2013, Louise Upton said in an email to Les Britzman and others at DCLG that her earlier concerns appeared not to have been particularly well addressed in the revised version.⁶²⁸⁶²⁸ {CLG00002780}. She sent a large number of comments on the draft document to Mr Britzman, including a reference to the need for contingency plans to provide for evacuation,⁶²⁹⁶²⁹ {CLG00002781/16}. but they were not sent on to DAC Cowup.⁶³⁰⁶³⁰ Cowup {Day196/60:6-9}. The substance of Ms Upton's comment on the need for an evacuation strategy was ultimately retained in the published version of GRA 3.2.

¶77.17 Ms Upton's comments also included a reference to the need for training to give incident commanders an understanding of when a full or partial evacuation of a residential building subject to a "stay put" strategy might be necessary.⁶³¹⁶³¹ {CLG00002781/19-20}. Again, her comment ultimately appeared in the published version of GRA 3.2 in substantially the same terms.

¶77.18 Following various discussions, and notwithstanding DCLG's reservations, the decision was taken to publish the revised GRA 3.2 without any further substantive amendments. The decision followed a conversation between Commissioner Dobson and Peter Holland,⁶³²⁶³² Cowup {Day196/106:2-10};{Day196/108:21}-{Day196/109:2}; {HOM00043991/3}. Chief Fire and Rescue Adviser, who, DAC Cowup recalled, had also been of the view that they should move towards publication.⁶³³⁶³³ Cowup {Day196/107:15-19}. Within DCLG, however, the document was described by some as a wasted opportunity and "not fit for purpose".⁶³⁴⁶³⁴ {HOM00043991/2}.

¶77.19 Be that as it may, GRA 3.2 in its final form clearly contemplated that the total evacuation of a high-rise building should be an important part of any fire and rescue service's contingency plan for a building and that incident commanders should not assume that compartmentation would invariably be maintained.⁶³⁵⁶³⁵ Phase 1 Report Volume IV paragraphs 27.2 and 27.3.

Review and amendment of PN633

¶77.20 In November 2011, the LFB published a revised version of PN633 which reflected changes to the policy considered necessary in the light of the Lakanal House and the Shirley Towers fires.⁶³⁶⁶³⁶ {LFB00102306}. DAC Cowup described it as a comprehensive revision.⁶³⁷⁶³⁷ Cowup {LFB00119849/84} page 84, paragraph 187. However, the revised policy contained no reference to the need to make contingency plans for evacuating the whole building, although crews visiting buildings pursuant to section 7(2)(d) of the 2004 Act were directed to have regard to the risk of fire spreading beyond the compartment of origin and the possible need for multiple rescues.⁶³⁸⁶³⁸ {LFB00102306/15}. There were references to evacuation throughout the policy, including a direction that the incident commander should follow the evacuation plan devised as part of the occupier's fire risk assessment unless the situation dictated otherwise,⁶³⁹⁶³⁹ {LFB00102306/12}. but there was no reference to the possibility that a building with a "stay put" strategy might need to be evacuated or indeed any explicit reference to the "stay put" principle at all.

¶77.21 The LFB's review of PN633 to bring it in line with the revised GRA 3.2 began in early 2013. DAC Cowup asked GM James A'Court, then part of the Operational Policy department, to co-ordinate it.⁶⁴⁰⁶⁴⁰ {LFB00085313}. GM A'Court asked SM Patrick Utting, then part of the Incident Management team, to take the lead on drafting the revised policy.⁶⁴¹⁶⁴¹ {LFB00086677}. DAC Cowup expected GM A'Court and SM Utting to keep him informed about any revisions to the draft GRA 3.2 as work went on and take them into account. He also expected them to have regard to any lessons arising out of the Lakanal House inquests, which had recently begun.⁶⁴²⁶⁴² {LFB00085313}; Cowup {Day196/143:8}-{Day196/141:15}.

¶77.22 DAC Cowup told SM Utting that transposing the relevant elements of GRA 3.2 into LFB policy was likely to be a relatively straightforward task.⁶⁴³⁶⁴³ Cowup {Day196/146:18}-{Day196/147:9}; Utting {Day198/12:23}-{Day198/13:4}. He did not recall specifically asking SM Utting to consider the coroner's rule 43 letters and SM Utting confirmed that he had not been asked to consider them as part of his work.⁶⁴⁴⁶⁴⁴ Cowup {Day196/147:15-20}; Utting {Day198/16:9-18}. SM Utting was similarly unaware of the contents of the Secretary of State's response to the coroner or of his commitment to including in the revised GRA 3.2 advice to incident commanders to inform decisions on evacuation.⁶⁴⁵⁶⁴⁵ Utting {Day198/55:17}-{Day198/57:6}.

¶77.23 The version of PN633 produced in 2015 was neither as clear nor as comprehensive as GRA 3.2. In particular, both the risk assessment and the gap analysis that SM Utting had produced for the purpose of his review of PN633 were based on an earlier draft of GRA 3.2 that pre-dated Ms Upton's comments in relation to "stay put" and evacuation.⁶⁴⁶⁶⁴⁶ Utting {LFB00121173/2} page 2, paragraph 5; {LFB00121174}; {LFB00030368}; Utting {Day198/94:21}- {Day198/95:19}. Further, neither of them contained any reference to cladding as a feature that crews should consider when gathering information, despite its being referred to in both the 2008 and the 2014 editions of GRA 3.2. There was no satisfactory explanation why the revised PN633 did not fully or accurately reflect the 2014 edition of GRA 3.2 on these important points.

¶77.24 In the section dealing with competence and training GRA 3.2 advised that incident commanders should understand when an evacuation strategy might become necessary in a residential building where a "stay put" strategy is normally in place. That was transposed into paragraph 7.46 of PN633 and to that extent, therefore, the policy did reflect a recognition that compartmentation may fail and that the incident commander may need to carry out a partial or total evacuation of a building subject to a "stay put" strategy.⁶⁴⁷⁶⁴⁷ Phase 1 Report Volume IV paragraph 27.6. However, no guidance was provided about when or how a decision of that kind should be made. SM Utting doubted whether it was feasible to include in a policy advice that would apply in all situations.⁶⁴⁸⁶⁴⁸ Utting {Day198/47:21}-{Day198/48:16}. That may be so, but it does not explain why no attempt was made to identify factors that might indicate to an incident commander that "stay put" advice should be withdrawn and an evacuation of some nature carried out. In those circumstances, it is not surprising that PN633 did not refer to the need to train incident commanders to recognise the need to withdraw "stay put" advice and carry out an evacuation.⁶⁴⁹⁶⁴⁹ Utting {Day198/66:3-12}. but no request for training was initiated in conjunction with the revision of PN633.⁶⁵⁰⁶⁵⁰ The Inquiry received no evidence to indicate that any training had been developed for the 2015 edition of PN633, and neither DAC Cowup nor SM Utting were able to confirm otherwise: Cowup {Day197/29:18-23}; Utting {Day198/91:2-18}. As Commissioner Roe accepted, at the time of the Grenfell Tower fire the LFB did not provide any guidance or direction in either its training or its policies about when and how a "stay put" strategy should be reversed.⁶⁵¹⁶⁵¹ Roe {LFB00083834/7-8} pages 7-8, paragraphs 28 and 29.

¶77.25 The guidance in GRA 3.2, to the effect that contingency plans for individual premises should cover the spread of fire beyond the compartment of origin and the possible need for multiple rescues, found its way into paragraph 4.8 of PN633, but without any specific reference to the need for a contingency plan. There was no reference to the need for an operational evacuation plan that could be implemented if a "stay put" policy became untenable.⁶⁵²⁶⁵² {LFB00001255/19}. SM Utting was unable to explain why that particular aspect of GRA 3.2 had not been incorporated into PN633.⁶⁵³⁶⁵³ Utting {Day198/60:13-25}-{Day198/61:2}. DAC Cowup told us that he had understood the phrase "contingency plans" in GRA 3.2 to relate only to high-risk premises, such as national heritage sites or landmark high-rise buildings, and that it would not be practicable to have individual contingency plans for every high-rise building in London.⁶⁵⁴⁶⁵⁴ Cowup {Day195/55:9-25}; {Day195/56:16-25}. SM Utting expressed a similar view.⁶⁵⁵⁶⁵⁵ Utting {Day198/58:3-15}. However, that is not the natural meaning of the expression as it appears in GRA 3.2, where it appears to refer to all high-rise buildings. Although it might not have been practicable to require crews to draw up individual contingency plans for all high-rise buildings, GRA 3.2 required fire and rescue services to consider generally whether and how contingency plans could assist crews and incident commanders. The stark conclusion is that PN633 did not properly reflect the requirements of GRA 3.2 in that respect.

Conclusions

¶77.26 The history of the revision of GRA 3.2 and the review of PN633 is of interest primarily for the light it sheds on the attitude of the LFB to the need to prepare for the evacuation of high-rise residential buildings subject to a "stay put" policy. The need to prepare contingency plans for an evacuation was included in GRA 3.2 as a result of the insistence of officials at DCLG rather than at the instigation of the LFB. The review of PN633 failed fully to reflect the current version of GRA 3.2, possibly because those at the LFB responsible for it did not think that the LFB needed such detailed advice and guidance or possibly because they did not attach sufficient importance to it. Whatever the reason, the close involvement of the LFB in the revision of GRA 3.2, coupled with the critical intervention of officials at DCLG, should have made it clear that producing contingency plans for a full evacuation was an essential part of fighting fires in high-rise buildings. Regrettably, however, that message was not properly absorbed by senior managers, and as a result operational firefighters were not properly prepared to deal with another major failure of compartmentation when it eventually occurred at Grenfell Tower.

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