Grenfell Tower Inquiry: Phase 2 Report · 2024
Chapter 78: The control room
Chapter 78: The control room
¶78.1 The Grenfell Tower fire presented the control room and all those who worked there with a challenge of unprecedented proportions. All those present on that night did what they could to deal with the huge volume of emergency calls and to pass vital information to the incident ground. However, mistakes were made, as described in the Phase 1 report, mainly as a result of inadequate training. It was therefore important for us to examine the way in which the control room had been run and its staff trained in the years immediately preceding the fire, to ensure, as far as possible, that a similar situation does not arise in the future.
Structure and management
¶78.2 The control room lies at the heart of the LFB's response to fires and other unexpected events as a result of which people's lives are at risk. It takes emergency calls from the public, despatches fire appliances to incidents and maintains communications with the incident ground. A description of its organisation and method of operation at the time of the Grenfell Tower fire is contained in chapter 7 of the Phase 1 report.
¶78.3 It is important to note at the outset that control room officers (CROs) are not merely call-handlers. As part of responding to emergency calls, they provide fire survival guidance when circumstances require. When providing fire survival guidance, a CRO becomes a first responder, giving critical advice to someone facing a life-threatening situation. Their role is, therefore, complex and proper performance of their functions is critical to the effective operation of the LFB. It depends on effective management of the organisation and the maintenance of critical skills through regular training.
¶78.4 Before 2015, responsibility for the operation of the control room lay with the Operational Prevention and Response department, itself part of the Deputy Commissioner's directorate.656 Dexter {LFB00032363/2} page 2, paragraphs 4 and 5. When in 2015 the Deputy Commissioner's directorate was abolished, that responsibility was transferred to the newly formed Directorate of Operations.657 Brown {LFB00032166/3-4} pages 3-4, paragraphs 5 and 9; George {LFB00032823/2} page 2, paragraph 6. From 2015 until 2017, the Director of Operations was AC Brown. From March 2017, AC George took over as Director of Operations.
¶78.5 Until 2011, CROs were divided into four watches covering two shifts within a 24-hour period.658 Lakanal Control Report {HOM00001124/7} paragraph 21. Each watch comprised 16 CROs and seven senior control officers under the command of a control commander.659 Lakanal Control Report {HOM00001124/8} page 8, Chart 1. Two senior operations managers (SOMs) managed two watches each and held certain other responsibilities which are discussed below. From 2010, the two SOMs were SOM Joanne Smith and SOM Lindsay Turner.660 Smith {LFB00121219/2-3} pages 2-3, paragraph 7. Following the fire, Joanne Smith was promoted to the rank of Deputy Assistant Commissioner and gave her evidence while holding that rank. At all material times she was a Senior Operations Manager and so, for clarity and consistency with the contemporaneous documentation, she will be referred to in that rank in this report. They were supported by assistant operations managers (AOMs). In overall command of the control room was the principal operations manager (POM), Scott Hayward.
102¶78.6 In addition to the watches staffing the control room, there were two support teams, each led by one of the SOMs. SOM Smith led the Technical Support Group, made up of one OM and two AOMs. SOM Turner led the Training team, made up of one OM and three AOMs. The Technical Support Group was responsible for ensuring that the systems used by the control room, including the mobilising system, were suitable for their purpose and capable of carrying out the functions required to enable CROs to do their work.661 Smith {LFB00121219/2-3} pages 2-3, paragraph 7, Smith {Day202/9:2-16}; Hayward statement {LFB00055191/17} page 17, paragraph 49. The Training team was responsible for developing core training and delivering it to CROs.662 Hayward {LFB00055191/17} page 17, paragraph 49; Lakanal Control Report {HOM00001124/8} paragraph 22. Its members were full-time trainers, although they were not trained as such. All of them were experienced CROs.663 SM Kelly's training audit report {LFB00055220/4} paragraph 9.
¶78.7 In April 2011, the shift pattern was changed. Instead of operating two shifts over 24 hours, CROs worked one of four shifts: a 12-hour day or night shift, or one of two overlapping 'short' shifts of eight hours.664 The operation of the shifts and the impact of the shift system on the time available for training is covered in more detail below. The shift times and watch numbers, together with the minimum staffing numbers, are set out in tabular form in POM Hayward's first witness statement: {LFB00055191/5} page 5, paragraphs 15-17
¶78.8 At about the time that the shift pattern was changed, the Technical Support Group and the Training team were merged to form a single team known as the Operational Support Team.665 Hayward {LFB00055191/17-18} pages 17-18, paragraph 49. Smith {LFB00121219/3} page 3, paragraph 7. Although the rest of the control room operated a shift system, the Operational Support Team, as a support body, operated only during the day shift.666 Smith {Day202/13:22-24}. The Operational Support Team trained CROs while the latter were 'on watch', i.e. when their watch was on duty, but during periods when they were not required to undertake control room duties.667 Hayward {LFB00055191/18} page 18, paragraph 52. Training was occasionally provided to CROs outside normal working hours.
¶78.9 The newly formed Operational Support Team contained five AOMs, later reduced to four.668 Hayward {LFB00055191/17-18} pages 17-18, paragraph 49. Within the Operational Support Team, the members of the former Technical Support Group retained their previous responsibilities and continued to report to SOM Smith.669 Smith {LFB00121219/3} page 2-3, paragraph 7. Those officers responsible for training reported to SOM Turner.670 Smith {LFB00121219/3} page 2-3, paragraph 7. SOM Smith said that following the merger no one person had been formally placed in charge of the Operational Support Team and that she and Lindsay Turner had shared that responsibility.671 Smith {Day202/15:15-18}.
¶78.10 In September 2012, SOM Smith was seconded to the Chief Fire Officers Association.672 Smith {LFB00121219/3} page 3, paragraph 8. At around the same time, SOM Turner left the control room for medical reasons.673 Hayward {Day200/189:11-21}. As a result, Victor Bagnelle and Keith Diamond were temporarily promoted to SOMs, replacing SOM Smith and SOM Turner respectively.674 Bagnelle {LFB00122821/2} page 2, paragraph 6; Smith {LFB00121219/3} page 3, paragraph 8.
¶78.11 In 2015, the LFB changed its mobilising system from one known as 'ProCAD' to a system known as 'Vision 4DS'. The introduction of a new mobilising system meant that between 2013 and 2015 the Operational Support Team had to design, prepare and deliver intensive training to enable the CROs to use it.675 Hayward {LFB00055191/19-20} pages 19-20, paragraph 56-60.
103¶78.12 In January 2015, SOM Smith returned from her secondment and assumed overall responsibility for the Operational Support Team.676 Smith {LFB00121219/4} page 4, paragraph 9. She continued to hold that responsibility until January 2020.677 Smith {LFB00121219/4} page 4, paragraph 9.
Senior officers and lines of responsibility
¶78.13 POM Hayward was in day-to-day command of the control room and reported directly to an Assistant Commissioner. Inevitably, the position held by that Assistant Commissioner within the LFB structure varied over time.678 Lakanal Control Report {HOM00001124/7} page 7, paragraph 19. For present purposes, it is sufficient to say that between 2009 and 2016 (apart from the period between May 2012 and October 2013 when the control room was commanded by its own Assistant Commissioner, AC Richard Chandler) POM Hayward usually reported to AC Brown, who had a broad range of other responsibilities. It was not until the appointment of AC George as Head of Operational Response in March 2016 that the control room once again had the benefit of its own Assistant Commissioner.
¶78.14 In December 2015, a few months before his appointment as Assistant Commissioner and Head of Operational Response, AC George was asked by AC Brown to lead what he described as a "cultural review" of the control room and its position within the organisation.679 George {Day205/10:1-2}; George {LFB00032823/4} page 4, paragraphs 13 and 15. In his role as Head of Operational Response, AC George was also responsible for the operation of the control room and mobilising, the operation of the Resource Management and Logistics Centre and the UK Fire and Rescue Services' National Co-ordination Centre.680 George {Day205/11:3-16}. He was also POM Hayward's line manager. AC George agreed that during that period POM Hayward had run the control room on a day-to-day basis, although he knew that AC George wanted to be kept informed about the type of decisions he was making.681 George {LFB00032823/4} page 4, paragraph 16; George {Day205/15:6-11}. AC George was also ultimately responsible for the delivery of training to CROs.682 George {Day205/22:1-5}. AC George knew that POM Hayward had delegated responsibility for training to SOM Smith and was content with that.683 George {Day205/21:2-10}. He explained that he had satisfied himself that it was an appropriate and effective step and had considered SOM Smith a very professional and experienced officer.684 George {Day205/21:11-23}. As Head of Operational Response, AC George reported directly to AC Brown.685 George {Day205/4:20-22}.
¶78.15 In April 2017, AC George succeeded AC Brown as Director of Operations.686 George {LFB00032823/10} page 10, paragraph 39. He was not replaced as Head of Operational Response, a position that ceased to exist.687 George {LFB00032823/10} page 10, paragraph 39. Although AC George retained responsibility for managing POM Hayward, he delegated all matters relating to the management of the control room to him.688 George {LFB00032823/10} page 10, paragraphs 39 and 42.
¶78.16 Following the Grenfell Tower fire, the management structure of the control room changed. In late 2018 or early 2019, AC George decided that a more senior officer needed to take over the day-to-day management of the control room.689 George {Day205/108:19-23}. POM Hayward was made redundant and Commissioner Cotton appointed AC Jonathan Smith as a new AC Operational Resilience and Control.690 George {Day205/108:21}-{Day205/109:4}. Hayward said that he left Brigade Control in July 2019: Hayward {Day199/5:1-3} and Hayward {LFB00086213/2} page 2, paragraph 7. Jonathan Smith {LFB00121171/4} page 4, paragraph 7. On 1 January 2021, SOM Joanne Smith was promoted to the newly created position of DAC for Control and Mobilising, reporting to AC Jonathan Smith.691 Smith {LFB00121219/2} page 2, paragraph 6; Smith {Day202/6:8-15}.
104Management meetings
¶78.17 Control room staff held regular meetings, usually monthly, which were attended by all staff other than the CROs.692 Hayward {Day199/27:20-23}. Although AC Chandler regularly attended those meetings, AC Brown and AC George did not.693 AC Chandler is recorded as attending or sending apologies to at least 6 meetings between 8 July 2012 and 9 November 2013. AC George is recorded as attending only part of the meeting on 8 March 2016 {LFB00123152/1} by way of an introduction to the staff. AC Brown considered that, as they were meetings of middle managers, it was for the POM and SOMs to manage them.694 George {Day205/13:2-5}.
¶78.18 POM Hayward regarded the meetings as an opportunity to discuss matters generally and inform the watch managers about any changes in the work.695 Hayward {Day199/27:16-19}. He also said that he would use them as a barometer to gauge whether there were any negative comments about training.696 Hayward {Day199/32:19} – {Day199/33:1} and Hayward {Day199/50:20} – {Day199/51:13}.
¶78.19 For a long time, POM Hayward reported to AC Brown as his line manager. AC Brown said that he used a variety of methods to monitor the performance of the control room and the way in which it was being managed. As Director of Operations he chaired a monthly Principal Management Board meeting of the area DACs, which he encouraged POM Hayward to attend,697 Brown {Day206/42:19-25}. but it appears that matters relating to the control room arose only occasionally and even then represented a relatively small part of what was discussed.698 See for example Principal Management Board Meeting draft minutes, 18 December 2013 {LFB00032168/5} where there the only involvement of Brigade Control is in relation to item 3.7 concerning the Lakanal Rule 43 Letter and item 4.3 regarding a report on a Radio MDT trial. He also met Scott Hayward once between each of those meetings, so that they met about every two weeks.699 Brown {Day206/42:25}-{Day206/43:4}. They also saw each other at meetings relating to one of the other areas for which AC Brown had strategic responsibility, if the subject matter affected the control room.700 Brown {Day206/43:4-10}. As an example, AC Brown referred to meetings concerning the Vision mobilising system.
¶78.20 AC Brown did not exercise any particular oversight over the training of CROs701 Hayward {Day199/37:16-18}; Brown {Day207/22:11-12}. because he considered that they were highly managed, in the sense that the control room contained approximately the same number of staff as a large fire station but a much higher proportion of managers.702 Brown {Day207/22:13-21}; Brown {Day207/11:4-20}.
The identification of remedial measures
¶78.21 The Lakanal House fire was a particularly significant event for the control room. The Lakanal House Board identified 13 pre-inquest actions relating to the control room, the most important of which for present purposes were those concerning a review of national guidance and LFB policy on providing fire survival guidance,703 The actions are set out in detail in the Lakanal Assurance Report {LFB00004801/12-15} Pre-Inquest actions 5 and 13. the training of CROs and their supervisors,704 Lakanal Assurance Report {LFB00004801/13-16} Pre-Inquest actions 8, 11, 12, 16 and 17. amendments to LFB Policy No. 539 (PN539) on emergency call-handling,705 Lakanal Assurance Report {LFB00004801/14} Pre-Inquest action 10. the creation of a policy (Policy No. 790 (PN790)) on handling fire survival guidance calls,706 Lakanal Assurance Report {LFB00004801/15} Pre-Inquest action 14. and amendments to the Reference Information Files (RIFs).707 Lakanal Assurance Report {LFB00004801/13} Pre-Inquest action 9.
105¶78.22 AC Brown was given responsibility for carrying out the pre-inquest actions,708 Hayward {Day199/146:2-7}; Minutes of Lakanal House Board on 15 September 2010 {LFB00055192/7-8} Appendix 1; Brown {LFB00032166/5-6} pages 5-6, paragraph 14. a task which he delegated to POM Hayward, although he provided him with support and met him from time to time to monitor progress.709 Brown {Day206/72:23-25}; Brown {LFB00084020/6} page 6, paragraph 10; Brown {Day206/73:6-16}. He was also received reports from DAC Cutbill who was a part of the Lakanal House action team: Brown {Day206/73:6-16}. POM Hayward did not ask AC Brown for additional resources to carry out the work.710 Brown {Day206/73:17-24}.
Policy and guidance – the gap analysis
¶78.23 Action 5 of the pre-inquest actions was the production of a gap analysis to identify any differences between national guidance on handling fire survival guidance calls and PN539.711 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/12}; Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/7-24}. The analysis was fundamental to shaping the control room's response to the Lakanal House fire.
¶78.24 The gap analysis had been completed by April 2010. It was produced by POM Hayward in conjunction with SOM Smith, DAC Cutbill, who was leading the investigation into the Lakanal House fire, and Thomas Davies, a member of the LFB's legal department.712 Hayward {LFB00055191/6} page 6, paragraph 20, first bullet point; Hayward {LFB00086213/2-3} pages 2-3, paragraphs 10-12; Smith {LFB00121219/9} page 9, paragraph 20; Email from SOM Smith to DAC Cutbill, POM Hayward, Thomas Davies and GM Zymanczyk on 2 February 2010 {LFB00118272}. SOM Turner, SM Hams and GM Zymanczyk also contributed to the first draft.713 Email from SOM Turner to DAC Cutbill and SM Hams copying in POM Hayward on 17 November 2009 {LFB00082629}; Email from SOM Turner to SM Hams on 19 November 2009 {LFB00075090}; Email from SOM Smith to DAC Cutbill, POM Hayward, Thomas Davies and GM Zymanczyk on 2 February 2010 {LFB00118272}. The analysis involved a comparison between two national guidance documents on the training of control room staff and the LFB's policy on emergency call management and its training materials on fire survival guidance.714 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/7-24}; Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/12}. The report made recommendations designed to address deficiencies identified in both national guidance and LFB policy and training.715 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/7-24}.
¶78.25 Although it is not clear whether the recommendations in the gap analysis were formally approved by the Lakanal House Board, some of the gaps that had been identified and some of the resulting recommendations gave rise to further pre-inquest actions intended to address them.716 Brown {Day206/79:5-9}; POM Hayward recalled that the gap analysis recommendations were accepted by the Lakanal House Board: {Day199/170:19-24}. However, the minutes of the meetings on 7 April, 5 May 2010 and 22 June 2010 do not make that clear: {LFB00060782/2}; {LFB00084028/3}; {LFB00055208/2-3}. That was certainly the case for the following recommendations:
106¶a. To include contributions from fire safety officers in training on handling fire survival guidance calls to make it consistent with national guidance.717 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/12} see 'Recommendations'. b. To amend PN539 to ensure that it reflected or complied with national guidance.718 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/8}; {HOM00001125/16} see 'Recommendations'. c. To carry out refresher training on handling fire survival guidance calls.719 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/23} see 'Recommendations'.
¶d. To improve certain points in national guidance on training on handling fire survival guidance calls.720 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/8}; {HOM00001125/11-20}; {HOM00001125/24}.
¶e. To establish a procedure for continuous communication between the control room and firefighters.721 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/21}. f. To audit training arrangements for the control room.722 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/24}.
¶g. To review LFB policy to ensure that it recognised the need to train supervising officers to provide support for CROs handling fire survival guidance calls.723 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/23}.
¶78.26 Although the RIFs used by CROs when handling fire survival guidance calls were not specifically addressed in the gap analysis, SOM Smith said that they had used the findings of the gap analysis to revise the RIFs after the Lakanal House fire.724 Smith {Day202/105:22-25}; Action Plan appended to the minutes of the meeting of the Lakanal House Board on 15 September 2010 {LFB00084031/8}; Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/13-14}.
¶78.27 On 8 December 2004, the government issued Fire and Rescue Service Circular 54-04 on 'Emergency Call Management' (FSC 54-04).725 FSC 54/04{LFB00055201/1}. It provided advice and a description of good practice developed jointly by the Chief Fire Officers Association and HM Fire Service Inspectorate to assist effective emergency call‑handling by fire and rescue services.726 FSC 54/04{LFB00055201/1}. It was produced following a review of emergency call‑handling which they had commissioned jointly in 2001.727 FSC 54/04{LFB00055201/2-3}. One of the review's objectives was to review existing guidance on handling emergency calls (including fire survival guidance calls).728 FSC 54/04{LFB00055201/2-3}.
¶78.28 The document summarised, in the form of national guidance, a three-stage approach to handling emergency calls with the objective of improving the way in which they were managed.729 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/10}. Annex A set out a generic three-stage approach to call‑handling called the "Emergency Call Management Protocol".730 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/7-12}. In summary, stage 1 involved obtaining information to assist the mobilising decision,731 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/7-8}. stage 2 involved obtaining information to support continuous assessment and ensure the safety of everyone involved,732 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/8-9}. and stage 3 was directed to ensuring the safety of the caller and members of the public.733 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/9-10}.
107¶78.29 Annex D contained "Fire call prompts", which included various 'prompts' in relation to fire survival guidance calls to be used at stage 3 of the call-handling approach, as well as a warning that stages 1 and 2 might need to be revisited during stage 3.734 Annex D of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/16-17}.
¶78.30 FSC 54-04 did not supersede FSC 10-93, so the available national guidance was to be found in a combination of the two documents.735 Emails between Michele McHugh (LFB) and Howard Jones (CLG) on 17 February 2010 {LFB00056548}. The minutes of the meeting of the Lakanal House Board on 5 May 2010 record that "It has been confirmed with CLG it is not intended that 54/04 supersede 10/93. However, it was noted that 10/93 was not on the CLG's website, although it has now been confirmed as an extant document." {LFB00084028/3}. Despite that, the LFB excluded FSC 54-04 from the scope of its gap analysis.736 Hayward {Day199/158:25} – {Day199/159:1-2}; Smith {Day202/102:14-23}; Smith {LFB00121219/9} page 9, paragraph 21; Brown {Day206/82:14-18}. POM Hayward told us that FSC 54-04 had been discussed with DAC Cutbill and Thomas Davies at the time and that they had all considered that it did not need to be included737 Hayward {Day199/158:25}-{Day199/159:1-2}. because it was concerned with the use of scripts, which the control room did not use at that time.738 Hayward {Day199/158:9-18}. He also said that he did not think that FSC 54-04 added anything to the training described in FSC 10-93.739 Hayward {Day199/158:9-18}. SOM Smith said the same.740 Smith {Day202/102:14-23}. AC Brown did not believe that the decision had been discussed with him and he did not recall approving it.741 Brown {Day206/82:19-24}; Brown {Day206/88:18-21}; Dobson {Day211/140:12-20}.
¶78.31 Notwithstanding the view of PO Hayward that FSC 54-04 added nothing of substance to FSC 10-93, it is hard to reconcile the decision to exclude FSC 54-04 either with the purpose of the gap analysis or with the contents of FSC 54-04 itself. One of the stated aims of the emergency call‑handling review had been to review FSC 10-93 and the training package 'Keeping People Safe' which the Home Office had issued to complement it. ('Keeping People Safe' described the training requirements for CROs and set out a recommended programme of training).742 Lakanal Control Report {HOM00001124/14} paragraph 61. The express purpose of issuing FSC 54-04 had been to improve the handling of emergency calls.743 FSC 54/04{LFB00055201/2-3}; Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol'{LFB00055201/10}. Moreover, it was expressly intended to provide national guidance.744 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/10}. It is surprising, therefore, that it was excluded from an analysis which was specifically aimed at comparing LFB policy and training with existing national guidance. Nor was it simply about using scripts or prompts, as suggested by POM Hayward. It provided general guidance on managing emergency calls, including fire survival guidance calls.745 Hayward {Day199/158:9-18}. Finally, and most significantly, FSC 54-04 went beyond the guidance in FSC 10-93 and 'Keeping People Safe' in a number of important respects. For example, it advised CROs that when taking fire survival guidance calls they should positively assess the age, gender, ethnicity and any mental and physical disability of the caller.746 Annex D of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/17}. Although 'Keeping People Safe' referred to the possibility that a caller might be incapacitated, or unable to communicate effectively because of language difficulties or confusion, it did not encourage CROs to explore those matters as part of their assessment.747 'Keeping People Safe' training {LFB00118948/5}. Further, FSC 54-04 encouraged CROs continually to assess the caller's situation and review their initial assessment in the light of changing circumstances.748 Two of the stated objectives of stage two of the emergency call‑handling protocol were to "review assessment in light of further information" and to "continue to assess the call" {LFB00055201/8}. Annex D warned CROs that they might need to revisit stage one and two of the emergency call-handling protocol {LFB00055201/17}. Neither FSC 10-93 nor 'Keeping People Safe' provided or reflected that guidance.749 FSC 10/93{LFB00084051}; 'Keeping People Safe' training {LFB00118948/5}.
108¶78.32 FSC 54-04 should therefore have been included in the gap analysis. The fact that it had not been included was noticed in November 2012, when those drafting the Lakanal Control Report realised that the guidance in FSC 54-04 on handling fire survival guidance calls had been omitted from training materials. It was noticed again in January 2013 when GM Lindridge drew attention to it in his review of the pre-inquest actions. Yet, for no obvious reason, no action was taken to ensure that all relevant national guidance had been incorporated into LFB policy and training.
¶78.33 The Lakanal Control Report (dated November 2012) noted that, although some CROs handling fire survival guidance calls had tried to find out what was happening at different stages of the call, the importance of continual re-assessment had not been included in LFB training materials. Despite that finding, the Lakanal Control Report did not recommend that FSC 54-04 should be specifically referred to in the gap analysis or that a reference to the need continually to reassess the caller's situation should be incorporated into LFB training and policy.
¶78.34 On 14 January 2013, DC Dexter forwarded a copy of GM Lindridge's review to AC Brown, to which she had added her comments, and invited his response.750 Email from DC Dexter to AC Brown on 14 January 2013 {LFB00085853/1}. She asked why the gap analysis did not include any reference to FSC 54-04.751 GM Lindridge's review dated 4 January 2013 with DC Dexter and AC Brown's comments {LFB00085854/5}. On 16 January 2013, AC Brown provided her with his response, which he said he had discussed with GM Lindridge.752 Email from AC Brown to DC Dexter on 16 January 2013 {LFB00085853/1}. He said that, as FSC 54-04 only partially addressed fire survival guidance calls, and then only in relation to age, gender and disability, the analysis had concentrated on the requirements of FSC 10-93. However, he said that AC Chandler had been instructed to remedy the omission in November 2013.753 GM Lindridge's review dated 4 January 2013 with DC Dexter and AC Brown's comments {LFB00085854/5}.
¶78.35 In evidence AC Brown accepted that, because age, gender and disability were factors that might affect a caller's ability to escape from a fire, FSC 54-04 should have formed part of the original gap analysis.754 Brown {Day206/83:17-23}. However, it was also important that the guidance it provided in relation to those factors be included in LFB policy and training. In those respects, AC Brown's reply to DC Dexter understated the relevance and importance of FSC 54-04. His reply also failed to draw her attention to the guidance in FSC 54-04 that a CRO should continually reassess the caller's situation, guidance that had been identified in the Lakanal Control Report as missing from LFB training.755 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 295. AC Brown said he believed that he had brought it to DC Dexter's attention during one of their regular meetings,756 Brown {Day206/85:4-10}. but in common with many similar assertions, we have seen no independent evidence that he did so.
109¶78.36 AC Brown said that the purpose of his reply to DC Dexter was just to confirm that he had asked AC Chandler to consider FSC 54-04 when GM Lindridge's review was revised.757 Brown {Day206/85:9-15}. AC Chandler was absent from work from late 2012 until April 2013. AC Brown said he could not remember whether AC Chandler had told him that POM Hayward would carry out the task in his absence or whether he had himself asked POM Hayward to do so,758 Brown {Day206/86:9-20}. but either way POM Hayward could not recall having received any such request.759 Hayward {Day199/164:5}-{Day199/165:1}.
¶78.37 When he revisited his review in November 2013 and May 2014, GM Lindridge again noted that FSC 54-04 had not been included in the gap analysis. He sought to justify its omission primarily on the basis that it did not seek to provide a full account of how fire survival guidance calls should be handled.760 GM Lindridge's review dated November 2013, as amended in May 2014 {LFB00083988/8}.
¶78.38 Although the exclusion of FSC 54-04 was apparently reconsidered, the gap analysis was not revised to include a comparison between LFB policy and training and FSC 54-04, despite AC Brown's assurance to DC Dexter that the omission would be remedied. The reasons given for not doing so are clearly unsound, because the purpose of the gap analysis was to compare LFB policy and training with national guidance and the guidance in FSC 54-04 on handling fire survival guidance calls clearly went beyond that contained in FSC 10-93 and 'Keeping People Safe'.
¶78.39 The failure to consider FSC 54-04 created a real risk that the guidance it contained, especially on assessing any impairments which might affect a caller's ability to leave and on continually reassessing the caller's situation, was not effectively reflected in LFB policy and training. As was found in the Phase 1 report, that risk materialised when PN539 was produced.761 Phase 1 Report Volume IV, paragraphs 29.45.e and 29.45.h.
¶78.40 The gap analysis was defective in two other significant respects: first, it failed to identify the fact that PN539 did not include the warning contained in FSC 10-93 about the dangers of offering false reassurance to a caller; secondly, despite having noted that FSC 10-93 and the LFB's training material did not emphasise the need for continual reassessment of the caller's situation, it failed to identify the fact that that guidance had also been omitted from PN539. We explore those defects and the likely consequences of them in relation to the revision of PN539 below.
¶78.41 FSC 10-93762 FSC 10/93 {LFB00003617/1}. and 'Keeping People Safe'763 'Keeping People Safe' training {LFB00118948/6}. both contained warnings that providing calming reassurance to callers trapped in buildings or otherwise exposed to danger could itself be dangerous. The gap analysis noted that FSC 10-93 acknowledged the possibility that an emotional bond might be formed between CROs and callers as calls progressed and emphasised that the relationship might be unhelpful because it might lead to callers' giving answers that they think CROs want to hear. CROs were therefore advised to exercise caution when offering reassurance to avoid giving callers a false sense of security. The gap analysis also noted that the LFB's training programme tended to encourage a strong attachment between callers and CROs by encouraging the use of reassuring phrases, which might have that effect.764 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/11}. It therefore recommended that LFB training reflect more closely the guidance in FSC 10-93 to prevent an emotional link being formed and false reassurance being given.765 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/11}.
110¶78.42 The gap analysis did not state whether PN539 dealt with the need for caution when offering reassurance to callers and therefore did not identify a gap or make any recommendation to amend PN539 in that respect. As it was, the version of PN539 dated 14 November 2007, which was current at the time, did not include a warning similar to that found in FSC 10-93 or 'Keeping People Safe'.766 PN539 dated 14 November 2007 {LFB00028382/20-21}. SOM Smith thought that that was because that guidance was to be delivered by the LFB through training rather than by policy,767 Smith {Day202/119:13-20}. but if that was the LFB's position, it was unreasonable. First, it does not explain why consideration of that aspect of PN539 was entirely omitted from the gap analysis. Secondly, it does not explain why the version of PN539 dated 14 November 2007 actively encouraged CROs to provide reassurance, including by the use of phrases such as "the firefighters will be with you very soon" and "I'm going to talk to you until the firefighters arrive", both of which might well promote a false sense of security.768 PN539 dated November 2007 {LFB00028382/21}. Thirdly, it ignored, or at least underestimated, the importance of PN539's stating clearly and fully the objectives and principles of, as well as the correct approach to, handling fire survival guidance calls. The clear and full expression of those principles would ensure that they would not be lost on anyone reading the policy (such as a CRO) and would provide a clear and comprehensive framework for training.
¶78.43 The failure to amend PN539 in those two respects was significant. As the chairman found in the Phase 1 report, PN539 had not been amended by the time of the Grenfell Tower fire and CROs invariably told callers that firefighters were on their way without having a sound basis for doing so.769 Phase 1 Report Volume IV, paragraph 29.45.f; Phase 1 Report Volume IV, paragraph 29.54.c. As a result, some callers were lulled into a false sense of security, remained in their flats and did not attempt to leave with sufficient vigour, or at all, despite the fact that escape was possible.770 Phase 1 Report Volume IV, paragraph 29.54.c.
¶78.44 The gap analysis also recommended that any revision of national guidance should contain advice to CROs to reassess the situation continually in order to be aware of changing conditions in the building and the caller's state of mind.771 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/14}. The basis for that recommendation is not entirely clear. The analysis failed to identify the fact that the current version of PN539 did not contain guidance that a CRO should continually reassess the caller's situation,772 PN539 dated 14 November 2007 {LFB00028382/20-21}. so it did not include an analysis of that aspect of the policy. POM Hayward said that it had been intended to amend PN539 in that way, but he could not explain why, if that had been the case, the gap analysis had not said so.773 Hayward {Day199/182:2-11}. SOM Smith could also not explain why: Smith {Day202/135:16-22}. That may explain why PN539 advised CROs to reassess the caller's situation, but did not emphasise the need for continual reassessment.774 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737}; Phase 1 Report Volume IV, paragraph 29.45.e. We discuss below the reasons for the deficiencies in the version of PN539 that was current at the time of the Grenfell Tower fire.
111The Lakanal Control Report
¶78.45 The LFB also undertook a detailed internal review of the part that the control room had played in the LFB's response to the fire at Lakanal House.775 Lakanal Control Report {HOM00001124/4} paragraph 1. The outcome was contained in a report entitled Fire at Lakanal, Havil Street, SE5 on 3 July 2009 – Role and Actions of the LFB Control published in November 2012 (the Lakanal Control Report).776 Lakanal Control Report {HOM00001124/4}. It was informed by the gap analysis, completed in April 2010, which had identified differences between national guidance and LFB policy and training on handling fire survival guidance calls.777 Lakanal Control Report {HOM00001124/4} paragraph 3. It set out the policy framework relating to the control room, the arrangements for training of CROs, and the working practices of the control room.778 Lakanal Control Report {HOM00001124/4} paragraph 1. It examined the Lakanal House fire from the perspective of the control room and identified numerous lessons.779 Phase 1 Report Volume I, paragraphs 8.5-8.8. The report included nine recommendations and points for further action.780 Lakanal Control Report {HOM00001124/51-55} Chapter G.
¶78.46 Of particular interest to us is the fact that the report suggested improvements to national and LFB policy on the training of CROs in handling fire survival guidance calls and managing the performance of control room staff.781 Lakanal Control Report {HOM00001124/51-53}, paragraphs 303 to 309, Recommendations 1, 2, 3, 4, 5. The report identified some recommendations that had already been completed, with some subject to a continuing process of review and implementation.782 Lakanal Control Report {HOM00001124/51-53}, paragraphs 303 to 309, Recommendations 1, 2, 3, 4, 5. The Lakanal Control Report was submitted to the coroner and on the basis of its contents she decided not to make any recommendations about handling fire survival guidance calls or training for CROs.783 Hayward {Day199/147:13} – {Day199/148:4}; Rule 43 Letter to Mr Ron Dobson, London Fire Commissioner dated 28 March 2013 {LFB00032158}. In her rule 43 letter she noted that the LFB had already undertaken extensive work to learn from its experience at Lakanal House.784 Rule 43 Letter to Ron Dobson, London Fire Commissioner dated 28 March 2013 {LFB00032158/1}. The striking similarities between the failings of the control room in handling fire survival guidance calls during the Lakanal House fire and those which were later seen in its response to the Grenfell Tower fire led us to examine whether the assurances given to the coroner about policy and training relating to handling fire survival guidance calls had been properly implemented and met their objective.785 Phase 1 Report Volume IV, paragraph 29.5. The short answer is that they had not and did not. We shall need to return to the Lakanal Control Report more than once in this chapter.
Review of PN539
¶78.47 The LFB's policy on emergency call management is contained in Policy No. 539. Pre-inquest action 10 was to review PN539 to ensure that it complied with national guidance.786 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/14}. That was a response to the identification in the gap analysis that PN539 did not reflect current guidance, particularly the appendix on fire survival guidance calls.787 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/8}; {HOM00001125/11-12}; {HOM00001125/16}; {HOM00001125/20}.
112¶78.48 Responsibility for carrying out the action was assigned to AC Brown,788 Action Plan appended to the minutes of the meeting of the Lakanal House Board on 15 September 2010 {LFB00084031/8}. The action was assigned to 'AC/SD', which meant "AC Service Delivery", who was AC Brown at the time. who had overall responsibility for PN539 as Head of Service Delivery & Mobilising.789 In both the version of PN539 dated 14 November 2007 that was current at the time of the Lakanal House fire {LFB00028382/1} and the version reviewed as current on 3 September 2010 {LFB00004735}, the 'owner' was designated as 'Head of Service Delivery & Mobilising'. However, he was not involved in reviewing and revising PN539, which he had delegated to POM Hayward.790 Brown {Day206/91:2-6}. Hayward {Day199/193:10-13}; Brown {LFB00084020/6} page 6, paragraph 10; Brown {LFB00084020/11} page 11, paragraph 23. POM Hayward, in turn, said that SOM Lindsay Turner and the Operational Support Team had carried out the task,791 Hayward {LFB00055191/7} page 7, paragraph 20. although in fact both he and SOM Smith were involved in and oversaw the work.792 Smith {LFB00121219/14} page 14, paragraph 34; Hayward {LFB00086213/5} page 5, paragraph 24; Emails between and Amelia Reynolds, Brigade Control Training Team Leader, POM Hayward, SOM Turner copying in SOM Smith between 13-21 July 2010 {LFB00057934}; Emails between SOM Smith and Amelia Reynolds between 2-3 September 2010 {LFB00109145}; Hayward {Day199/189:5}-{Day199/190:5}.
¶78.49 The initial review and revision of PN539 was completed by 3 September 2010,793 PN539 reviewed as current on 3 September 2010 {LFB00004735}. as POM Hayward and SOM Smith reported to the Lakanal House Board on 15 September 2010.794 Minutes of the Lakanal House Board meeting on 15 September 2010 {LFB00055192/2} item 5.15(1). However, they did not present the revised version of PN539 to the board,795 Smith did not recall the reviewed version of PN539 being presented to the Lakanal House Board: Smith {Day202/113:22}-{Day202/114:17}. There is no record of the updated policy being presented for approval at the meetings of the Lakanal House Board on 15 September 2010 {LFB00055192/2-3}, 8 November 2010 {LFB00084032/1} or 22 December 2010 {LFB00084033/2}, when the action was marked as completed. It ceased to be an agenda item thereafter. which never formally approved it.796 SOM Smith did not think anyone had approved it: Smith {Day202/112:21-23}. Nor did AC Brown,797 Brown {Day206/91:5-6}. who told us that it was not normal practice for managers in his position to read through a policy and approve the changes.798 Brown {Day206/91:15-24}. SOM Smith said that the owner of the policy had ultimate responsibility for approving it, but in practice she did not think that had happened: Smith {Day202/111:22}-{Day202/112:1}. As a result, the revisions made to PN539 after the Lakanal House fire were not subjected to any form of approval process and were not examined by the senior manager responsible for them.799 SOM Smith did not think that anyone had approved it: Smith {Day202/112:21-23}. She said that she was not aware of anyone whose authority was required to make changes to PN539: Smith {Day202/110:23}-{Day202/111:6}.
¶78.50 PN539 was amended nine more times before the Grenfell Tower fire, most significantly Appendix 3, which covered fire survival guidance calls. It was amended on 3 February 2011 and 28 March 2014.800 As shown by the audit trail to PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/22}. The version of PN539 that was in force at the time of the fire had last been amended on 6 April 2017.801 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737}. The Phase 1 report found that the policy was significantly defective in many respects. In particular, it failed to state clearly that the four principles of "escape, assess, protect and rescue" required continual reassessment of the caller's situation,802 Phase 1 Report Volume IV, paragraph 29.45.e. it did not contain a warning that it is not always safe to assume that the fire and rescue service is on its way to rescue the caller,803 Phase 1 Report Volume IV, paragraph 29.45.f.8. it did not make it clear that, if a fire survival guidance call required a CRO to remain on the line, the number of simultaneous fire survival guidance calls could never exceed the number of CROs available,804 Phase 1 Report Volume IV, paragraph 29.45.b.7. it contained no advice or guidance to assist CROs and senior managers when handling a large number of fire survival guidance calls concurrently805 Phase 1 Report Volume IV, paragraph 29.45.g. and it did not require CROs to find out whether the caller was, or had with them, a person who, for whatever reason, would require help to evacuate.806 Phase 1 Report Volume IV, paragraph 29.45.h. We explore the reasons for those defects below.
113¶78.51 The exclusion of FSC 54-04 from the gap analysis created a risk that the guidance it contained on the need continually to reassess the caller's situation would not be reflected in PN539. Curiously, however, the version of PN539 dated 3 September 2010, which was the result of the first revision following the Lakanal House fire, did add advice to CROs to reassess continually the caller's situation,807 PN539 dated 3 September 2010 {LFB00004735/16}; PN539 dated November 2007 {LFB00028382/20}. but it was replaced in the version dated 3 February 2011 with advice to reassess the caller's situation, providing some example questions.808 PN539 dated 3 February 2011 {LFB00028601/16-17}. The clear and unambiguous emphasis on continual reassessment had thus been removed and the policy remained in that form until the Grenfell Tower fire.809 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/16-17}.
¶78.52 It is evident from the version of PN539 that SOM Smith sent to POM Hayward on 3 February 2011 with tracked changes that she was the person who removed the requirement for continual reassessment.810 Email from SOM Smith to POM Hayward on 3 February 2011 {LFB00109464}; Version of PN539 with tracked changes made by SOM Smith attached to her email to POM Hayward on 3 February 2011 {LFB00109465/17}. When asked, she could not account for that,811 Smith {Day202/137:5-8}. but she suggested that the amendments amounted to the same thing and that the training made that clear.812 Smith {Day202/137:8-12}. She told us that the need for continual reassessment, although not stated explicitly, was implied in the revised version813 Smith {Day202/137:12-15}. and that training emphasised the need for continual reassessment.814 Smith {Day202/137:8-17}. AC Brown said essentially the same.815 Brown {Day206/99:3-22}. However, those explanations ignored, or at least underestimated, the vital importance of ensuring that PN539 stated clearly and comprehensively the objectives, principles and approach for handling fire survival guidance calls.
¶78.53 As set out above, the Lakanal Control Report, dated November 2012, which post-dated the removal by SOM Smith of the passage emphasising the need for continual re-assessment, found that the guidance in FSC 54-04 was not included in LFB training and that there might be a tendency among CROs to limit reassessment due to a desire to keep the caller safe.816 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 295. It recommended that PN539 should be revised to ensure compliance with national guidance and to reflect the lessons identified in the report.817 Lakanal Control Report dated November 2012 {HOM00001124/52} paragraph 304. However, it also recorded that PN539 had already been revised in February 2011,818 Lakanal Control Report dated November 2012 {HOM00001124/52} paragraph 304. implying that no further action was required. There is nothing to suggest that the recommendation prompted any further consideration of PN539 to ensure that it reflected in full the experience of the Lakanal House fire. AC Brown confirmed that he had not asked for any further work to be done on it.819 Brown {Day206/102:4}-{Day206/103-4}.
114¶78.54 In his review dated 4 January 2013, GM Lindridge found that PN539 did not incorporate the guidance in FSC 54-04,820 GM Lindridge's review dated 4 January 2013 {LFB00085854/6}. a conclusion which he said had been reported to AC Brown as AC Operations, Prevention and Response. GM Lindridge understood that his observations would be considered in a forthcoming review of policy on handling fire survival guidance calls,821 GM Lindridge's review dated 4 January 2013 {LFB00085854/6}. but no such review was undertaken, as AC Brown confirmed.822 Brown {Day206/95:6-18}. AC Brown said that he had asked AC Chandler and then POM Hayward, in AC Chandler's absence, to review the gap analysis in relation to FSC 54-04 and to apply any resulting recommendations,823 Brown {Day206/94:22}-{Day206/95:5}. but that was not done and no good explanation was given for the omission.
¶78.55 Those were yet more missed opportunities to ensure that PN539 contained the important requirement for continual reassessment.
¶78.56 The version of PN539 dated 3 September 2010, which was the result of the initial revision following the Lakanal House fire, actively encouraged CROs to offer callers reassurance,824 PN539 dated 3 September 2010 {LFB00004735/16}. suggesting the use of phrases such as "the firefighters will be with you very soon" and "the firefighters know where you are".825 PN539 dated 3 September 2010 {LFB00004735/16}. It also referred the CROs to the RIFs to assist them in providing reassurance to the caller that help was on its way.826 PN539 dated 3 September 2010 {LFB00004735/16}. However, the version dated 3 February 2011 largely removed that guidance, apart from the reference to the RIFs.827 PN539 dated 3 February 2011 {LFB00028601/16}. It simply included advice to reassure the caller.828 PN539 dated 3 February 2011 {LFB00028601/16}. It would seem that those carrying out the review of PN539 in 2011 had in mind, to an extent, the guidance in FSC 10-93 and 'Keeping People Safe'. SOM Smith confirmed as much when she said that the emphasis on reassurance had been removed because of the warning in FSC 10-93 and the investigation into the Lakanal House fire.829 Smith {Day202/124:12-22}.
¶78.57 In those circumstances, it is hard to understand why those who updated PN539 in February 2011, a group which included SOM Smith and POM Hayward, did not include an explicit warning to CROs, as set out in the national guidance, against providing reassurance to callers which might promote a false sense of security.830 Email from SOM Smith to POM Hayward on 3 February 2011 {LFB00109464}; Version of PN539 with tracked changes made by SOM Smith attached to her email to POM Hayward on 3 February 2011 {LFB00109465}; Emails between SOM Smith and POM Hayward on 3 February 2011 {LFB00058030}.
¶78.58 SOM Smith said that training had included clearer instructions on the warning and there might also have been advice in the RIFs.831 Smith {Day202/125:13}-{Day202/126:3}. That was certainly not so in the case of the RIFs, as the chairman found in the Phase 1 report. In any event, it ignored or, at least, underestimated the important role of the policy and placed too much reliance on training.832 Phase 1 Report Volume IV, paragraph 29.49.c.
¶78.59 The Lakanal Control Report dated November 2012 noted that CROs handling fire survival guidance calls during the Lakanal House fire expected fire crews to arrive quickly (as they usually did) and advised callers to remain in their flats and wait to be rescued rather than helping them to assess whether escape was possible.833 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 293. The implication was that an assumption that firefighters would rescue a caller promptly, or at all, was not always well founded. That echoed the warning in FSC 10-93 and 'Keeping People Safe' against providing reassurance to a caller which might produce a false sense of security.834 FSC 10/93 {LFB00003617/1} paragraph 2; 'Keeping People Safe' training {LFB00118948/6}. However, despite the recommendation in the Lakanal Control Report, that aspect of PN539 was not reconsidered and the policy was not amended to include an appropriate warning.
115¶78.60 Further, in his review dated 4 January 2013, GM Lindridge found that PN539 had been reviewed and did not contradict FSC 10-93, but that it might be said not to contain all the information in the national guidance.835 GM Lindridge's review dated 4 January 2013 {LFB00085854/13}. In a comment on the draft DC Dexter asked whether PN539 complied with national guidance, to which AC Brown replied that it did and that the action had been completed, both in word and spirit,836 GM Lindridge's review dated 4 January 2013 {LFB00085854/13}. but that was wrong because PN539 did not include a warning against providing false reassurance.837 PN539 dated 3 February 2011 {LFB00028601/16}; FSC 10/93 {LFB00003617/1} paragraph 2; 'Keeping People Safe' training {LFB00118948/6}. It appears that, as a result, no action was taken to investigate and deal with this particular aspect of GM Lindridge's review.
¶78.61 The failure to include FSC 54-04 in the gap analysis created a real risk that the guidance it contained about assessing any impairments which might impede a caller's ability to escape would not be reflected in LFB policy and training. In fact, the version of PN539 dated 14 November 2007 did include a requirement for CROs to assess whether callers had any relevant disabilities,838 PN539 dated 14 November 2007 {LFB00118944/20}. but for no obvious reason that requirement was removed from later versions and was not reinstated before the Grenfell Tower fire.839 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/16-17}. SOM Smith could not explain why.840 Smith {Day203/13:24}-{Day202/14:4}. She told us that she had not been involved in the revision of PN539 in 2010,841 Smith {Day203/14:3-5}. but email exchanges at the time reveal that she, together with POM Hayward, SOM Turner and Amelia Reynolds, had all contributed to it.842 Emails between and Amelia Reynolds, Brigade Control Training Team Leader, POM Hayward, SOM Turner copying in SOM Smith between 13-21 July 2010 {LFB00057934}; Emails between SOM Smith and Amelia Reynolds on 2-3 September 2010 {LFB00109145}; Hayward {Day199/189:5}-{Day199/190:5}. SOM Smith said that she was not aware of any positive decision to omit the advice on assessing disability843 Smith {Day203/14:13-16}. and could not say whether it had been omitted accidentally.844 Smith {Day203/15:3-7}. She said that she had made sure that the questions on disability were included in the training and the RIFs,845 Smith {Day203/14:5-9}; Smith {Day203/14:20-22}. but that was not the case as far as the RIFs were concerned.
¶78.62 The RIF for Operators dated 12 March 2007 had contained a prompt to ask whether a caller had a disability and whether their mobility was impaired, but that prompt was removed from the revised version approved by SOM Smith on 23 February 2011.846 RIF for Operators approved on 12 March 2007 {LFB00121224/2}; RIF for Operators approved on 23 February 2011 {LFB00121240}. However, unlike PN539, a later version of the RIF for Operators approved by SOM Bagnelle on 3 April 2014 reinstated a prompt that did effectively address the requirement to assess disability, albeit with rather less emphasis than previously.847 RIF for Operators approved on 3 April 2014 {LFB00122837/2} paragraph 1.5. That was included following a report from a command unit training workshop with the control room: Bagnelle {LFB00122821/5} page 5, paragraph 15 and report {LFB00122833/2}.
116¶78.63 SOM Smith's evidence was that she had thought that the reason why the requirement to assess disability had not been reinstated in PN539 in February 2011 and thereafter was because it had been covered by training and in the RIFs and it was felt that that was sufficient.848 Smith {Day203/16:14-22}. However, the RIFs were not amended until April 2014 and we do not consider that training could adequately compensate for its omission from the policy, since that leaves too much to the discretion of the individual trainer. SOM Smith told us that it was not unusual for a CRO to assess the caller's age and ability to leave the building,849 Smith {Day203/16:22-25}. She effectively accepted that much depended on what information the caller provided.850 Smith {Day203/17:1-13}. If so, that was not consistent with national guidance, because FSC 54-04 clearly required CROs to carry out a positive assessment of a caller's age, gender, ethnicity and mental or physical disability.851 FSC 54/04 {LFB00055201/17}. SOM Smith accepted that the LFB was not following the guidance in FSC 54-04;852 Smith {Day203/17:14}-{Day203/18:3}. she also accepted that, if it were left to the caller to volunteer information, there was a risk that it might not be given, which is exactly what happened in some cases during the Grenfell Tower fire.853 Smith {Day203/17:14}-{Day203/18:3}; Phase 1 Report Volume IV, paragraph 29.76.
¶78.64 In his review dated 4 January 2013 GM Lindridge found that PN539 did not include the guidance called for by FSC 54-04.854 GM Lindridge's review dated 4 January 2013 {LFB00085854/6}. That omission might, therefore, have been made good if some action had been taken in response to his finding. However, it was not.
¶78.65 A further opportunity to remedy the omission came in the form of GRA 3.2, published in February 2014,855 GRA 3.2 'Fighting fires – In high rise buildings' dated February 2014 {LFB00001255}. which introduced new requirements for handling fire survival guidance calls.856 GRA 3.2 {LFB00001255/20}; GRA 3.2 {LFB00001255/29-31}; Cowup {Day195/64:4-8}; Cowup {Day195/99:1-5} AC Brown was involved in the consultation process which preceded the document.857 Email from Michele Kunneke to AC Brown and others on 10 May 2012 {LFB00093616}. However, it is reasonably clear that he did not discuss it with anyone else responsible for the operation of the control room.
¶78.66 GRA 3.2 introduced a requirement for fire and rescue authorities to have effective arrangements in place for handling fire survival guidance calls from those who believe they are unable to leave a building due to disability, poor mobility, illness or the effects of fire. However, AC Brown admitted that he had taken no specific steps following the publication of GRA 3.2 to ensure that the LFB had such arrangements in place because he was satisfied that CROs would obtain that information and that adequate arrangements were therefore already in place.858 Brown {Day206/153:22}-{Day206/154:4}. He had not considered asking anyone responsible for the control room to review PN539 to ensure that it was consistent with GRA 3.2.859 Brown {Day206/154:24}-{Day206/155:10}. Unsurprisingly, in the light of their ignorance of GRA 3.2, POM Hayward and SOM Smith did not carry out any such review themselves, nor did POM Hayward ask anyone else to do so.860 Smith {Day203/20:9-16}; Hayward {Day200/54:2-17}.
¶78.67 The direct result of this cluster of failings was that the LFB did not introduce, or reintroduce, into PN539 a provision for CROs to enquire positively whether callers had disabilities or other impairments of a kind that might affect their ability to leave the building.
117¶78.68 A further, and perhaps final, opportunity to remedy that particular deficiency was by way of an equality impact assessment, which ought to have been undertaken in order to consider the likely effect of the policy on different groups of people. However, it is evident from the audit trail in the version of PN539 which was current at the time of the Grenfell Tower fire that no one carried out such an assessment after 17 September 2008.861 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/22}.
¶78.69 AC Brown accepted that it had been his responsibility to ensure that an equality impact assessment was carried out,862 Brown {Day206/109:20}-{Day206/110:2}. but he said that such an assessment was carried out only when changes were made that required one.863 Brown {Day206/110:13-16}. He did not think that they had decided it was necessary to carry out an equality impact assessment when PN539 had subsequently been reviewed after 2008.864 Brown {Day206/110:3-25}. However, he acknowledged that in hindsight one should probably have been carried out at some point.865 Brown {Day206/110:19-21}.
¶78.70 In our view, the warning signs were there at the time for all to see. AC Brown simply did not heed them. It is surprising that he took no steps to alert the LFB's senior management to the existence, let alone the contents, of GRA 3.2 or to recognise the need for an equality impact assessment. We regard those as serious failings on his part.
The Reference Information Files
¶78.71 Pre-inquest action 9 was to revise the Reference Information Files (RIFs) used by CROs when giving fire survival guidance in order to ensure that they complied with national guidance.866 Lakanal Assurance Review dated August 2018 {LFB00004801/13}. There were two RIFs: a RIF for Operators, which was a prompt sheet or script to assist with handling fire survival guidance calls, and a RIF for Supervisors, which described their role in supporting CROs during fire survival guidance calls and passing information to the incident ground.867 Lakanal Assurance Review dated August 2018 {LFB00004801/14}.
¶78.72 SOM Turner, SOM Smith and the Operational Support Team carried out the revisions to the RIFs in discussion with POM Hayward.868 Hayward {LFB00055191/7} page 7, paragraph 20; Smith {LFB00121219/11} page 11, paragraph 26; Smith {Day203/26:11}-{Day203/28:7}. SOM Turner undertook the initial review;869 Smith {Day203/26:11-24}. SOM Smith then proposed further revisions.870 Smith {LFB00121219/11} page 11, paragraph 26; Smith {Day203/26:11-24}. They were completed by January 2011 and circulated to control room staff on 23 February 2011.871 Smith {LFB00121219/12} page 12, paragraph 27; Email from SOM Smith to all Brigade Control Staff on 23 February 2011 {LFB00121237}; RIF for Operators approved on 23 February 2011 {LFB00121240}; RIF for Supervisors approved on 23 February 2011 {LFB00111192}.
¶78.73 SOM Smith said that the primary reason for revising the RIFs following the Lakanal House fire was to prepare for the next large-scale incident.872 Smith {LFB00121219/12} page 12, paragraph 28. Senior management wanted to ensure that the RIFs contained clear advice in relation to fires in high-rise residential buildings.873 Smith {LFB00121219/12} page 12, paragraph 28. The RIF for Operators was, therefore, amended so that there were sections on different types of buildings, with a separate section on purpose-built blocks of flats.874 Smith {LFB00121219/12} page 12, paragraph 28; RIF for Operators approved on 23 February 2011 {LFB00121240/10-19}. SOM Smith said that she had also used the findings of the gap analysis to amend the RIFs.875 Smith {Day202/105:22-25}.
118¶78.74 SOM Smith approved the revisions to the RIFs.876 RIF for Operators approved on 23 February 2011 {LFB00121240/24}; RIF for Supervisors approved on 23 February 2011 {LFB00111192/5}; Smith {Day203/26:25}-{Day203/27:4}. Although she discussed some of them with POM Hayward, it is reasonably clear that he did not review or approve the revisions, even though responsibility for final approval lay with him.877 Smith {Day203/27:5}-{Day203/28:17}. Further, although POM Hayward and SOM Smith informed the Lakanal House Board on 15 September 2010 and 4 February 2011 of the fact that the RIFs had been revised, they did not describe the substance of the revisions.878 Minutes of Lakanal House Board meeting on 15 September 2010 {LFB00055192/2} item 5.6; Minutes of Lakanal House Board meeting on 4 February 2011 {LFB00055215/2} item 5.5; Smith {Day202/28:14-20}. As a result, the Lakanal House Board did not formally review and approve the changes.
¶78.75 On 27 June 2011, AOM Bonnett sent an email to SOM Smith, SOM Turner, AOM Sharp and AOM O'Shea in which he criticised the training relating to fire survival guidance as being inconsistent with the revised RIF for Operators.879 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O'Shea on 27 June 2011{LFB00028381/1-2}. He concluded that, because the RIF had been specifically designed to assist CROs during fire survival guidance calls, it should be central to, and consistent with, training.880 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O'Shea on 27 June 2011{LFB00028381/3}. He also suggested that training exercises should be carried out to test the suitability of both the RIF for Operators and the RIF for Supervisors.881 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O'Shea on 27 June 2011{LFB00028381/3-4}.
¶78.76 SOM Smith forwarded the email to POM Hayward, expressing her agreement with AOM Bonnett's findings.882 Email from SOM Smith to POM Hayward on 27 June 2011{LFB00028381/1}. Despite her agreement, however, no training was provided on the RIFs, nor were they subject to a test exercise.883 Smith {Day203/29:16}-{Day203/30:24}; Smith {Day203/34:3}-{Day203/35:8}; Smith {LFB00121219/13} page 13, paragraphs 30-31; Smith {MET00080606/20}. Control room staff were simply notified that the RIFs had been revised and told to familiarise themselves with their contents.884 Email from SOM Smith to all Brigade Control Staff on 23 February 2011 {LFB00121237/1}. SOM Smith said that was because staff could look at the RIFs at any time they wished and because, contrary to AOM Bonnett's opinion, they were consistent with the fire survival guidance training.885 Smith {Day203/30:25}-{Day203/32:5}.
¶78.77 We do not understand how senior management could have satisfied themselves that CROs and supervisors understood the nature and extent of the changes to the RIFs that had been brought about as a consequence of the Lakanal House fire without providing them with any formal training. As it was, the training records we have seen show that no staff reviewed the RIFs in 2011 and that only two did so in 2012.886 Brigade Control training records 2011-2018 {LFB00041763} columns Y, Z and AA.
119¶78.78 The RIFs were revised again in early 2013 following discussions with GM Lindridge.887 Bagnelle {LFB00122821/5} page 5, paragraphs 14-15; Email from AOM Bonnett to SOM Bagnelle on 10 January 2013 {LFB00122822/2-3}. SOM Vic Bagnelle instructed AOM Bonnett and AOM Pope of the Operational Support Team to carry out the revisions, which he then reviewed and approved on 18 February 2013.888 Bagnelle {LFB00122821/5} page 5, paragraph 15; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}. The primary aim of those revisions was to reduce the length of the RIFs to make them more manageable.889 GM Lindridge's Review dated 4 January 2013 {LFB00085854/5}; Email from GM Lindridge to SOM Bagnelle, POM Hayward, AC Brown and others on 9 January 2013 {LFB00118958/1}; Email from SOM Bagnelle to OST on 11 January 2013 {LFB00122822/2}; Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; Bagnelle {LFB00122821/6} page 6, paragraph 17. As a result, the separate sections on different building types, including purpose-built blocks of flats, were removed.890 Smith {LFB00121219/12} page 12, paragraph 28; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}.
¶78.79 Although SOM Bagnelle reported to POM Hayward and AC Brown on the progress of their work, we have not seen any evidence that POM Hayward or the Lakanal House Board reviewed or approved the revised versions.891 Bagnelle {LFB00122821/5} page 5, paragraph 15.
¶78.80 AOM Bonnett circulated the revised RIFs to control room staff on 18 February 2013.892 Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}. As before, they were simply instructed to familiarise themselves with the contents.893 Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}. The training records indicate, however, that most staff did not review the RIFs in 2013 and there are no records of any staff having done so thereafter.894 Brigade Control training records 2011-2018 {LFB00041763}; Hayward {LFB00055191/27} paragraph 77.
¶78.81 SOM Sharp made further amendments to the RIFs in 2014, which were approved by SOM Victor Bagnelle on 3 April 2014.895 Bagnelle {LFB00122821/5-6} pages 5-6, paragraph 14-16; RIF for Operators approved on 3 April 2014 {LFB00003542}. That then remained the version of the RIF for Operators in force at the time of the Grenfell Tower fire.896 RIF for Operators approved on 3 April 2014 {LFB00003542}. The RIF for Supervisors, however, was revised once more before the Grenfell Tower fire in April 2016, although the revisions do not appear to have been formally approved.897 Bagnelle {LFB00122821/5} page 5, paragraph 14; RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}. The version in force at the time of the Grenfell Tower fire had, therefore, been approved on 3 April 2014 and subsequently amended on 2 April 2016.898 RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}.
¶78.82 In his Phase 1 report the chairman found that the RIF for Operators was unsatisfactory in a number of respects.899 Phase 1 Report Volume IV, paragraph 29.49. It contained no clear guidance on what was meant by "affected" by heat, smoke or fire or how it was to be assessed, it contained no clear guidance on how to assess the safety of escape routes if the caller was, or claimed to be, affected by heat, smoke or fire, or simply felt unsafe, it did not tell CROs that assurances that firefighters would rescue callers should be based on information from the incident ground rather than expectations or assumptions, it contained no guidance on what information CROs should gather in order to assist the control room supervisor or incident commander to decide whether a partial or total evacuation of the building should be carried out and it contained no guidance on what advice CROs should give to a caller once a decision had been made to carry out a full or partial evacuation of the building. He also found that the RIF for Supervisors contained similar defects. In particular, it contained no guidance on how supervisors should gather information from CROs to enable them to form an overall assessment of the situation in order to assist incident commanders to decide whether to revoke "stay put" advice.900 Phase 1 Report Volume IV, paragraph 29.50. We consider the reasons for those defects below.
120¶78.83 The section of the RIF for Operators dated 23 February 2011 that dealt with giving fire survival guidance to a person trapped in a purpose-built flat, advised the CRO to ask the caller whether the flat was being "affected" by heat or smoke. If the caller said it was not, the advice was to say that it would usually be safer to stay in the flat, but that if the situation changed, or the caller felt unsafe, the better course was to get out and stay out.901 RIF for Operators approved on 23 February 2011 {LFB00121240/14}.
¶78.84 SOM Smith had been responsible for drafting that advice.902 Smith {Day203/70:17-20}. She said that she had taken the word "affected" from FSC 10-93, although that word is not used in the circular.903 Smith {Day203/70:21}-{Day203/71:1}. She understood it to mean that heat or smoke was entering the flat and directly affecting the caller in some way, such as interfering with their breathing;904 Smith {Day203/71:2-14}. in effect, that compartmentation had been breached.905 Smith {Day203/71:2-14}. When preparing the RIFs, SOM Smith had asked John Bradbury, DAC Fire Safety Regulation Delivery, and AC James Knighton, AC Operational Policy, what information it would be helpful to obtain from a caller to enable a CRO to determine whether the person was affected by fire, heat or smoke,906 Smith {LFB00121219/15} page 15, paragraph 36. but they had not given her any help.907 Smith {Day203/69:24}-{Day203/70:6}. However, despite her own understanding and her difficulty in obtaining assistance, she did not consider including in the RIF an explanation of what "affected" meant or further prompts to guide a CRO when giving advice.908 Smith {Day203/70:3-10}; Smith {Day203/71:15}-{Day203/72:8}.
¶78.85 The RIF for Operators also suggested that, if a caller was, or felt themselves to be, "affected" by fire, heat or smoke, CROs should ask about possible escape routes.909 RIF for Operators approved on 23 February 2011 {LFB00121240/14-15}. It then set out questions aimed at finding out whether an alternative escape route was available.910 RIF for Operators approved on 23 February 2011 {LFB00121240/15}. However, the RIF did not suggest how to assess the safety of any potential escape route. SOM Smith said that when she drafted the RIF she must, at some point, have considered whether such guidance was needed, given the questions on exploring alternative escape routes that she had included.911 Smith {Day203/73:1-3}. If so, it must follow that she decided not to include such guidance.
¶78.86 The revised versions of the RIFs for Operators dated 18 February 2013 and 3 April 2014 contained the same defects.912 RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Operators approved on 3 April 2014 {LFB00003542}. The revision in 2013 concentrated principally on reducing its length and making it easier to use rather than on making substantive changes.913 GM Lindridge's Review dated 4 January 2013 {LFB00085854/5}; Email from GM Lindridge to SOM Bagnelle, POM Hayward, AC Brown and others on 9 January 2013 {LFB00118958/1}; Email from SOM Bagnelle to OST on 11 January 2013 {LFB00122822/2}; Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; Bagnelle {LFB00122821/6} page 6, paragraph 17. It is not surprising, therefore, that SOM Bagnelle and SOM Sharp do not appear to have considered providing guidance on the meaning of being "affected" by fire, heat or smoke or on assessing the safety of an escape route. However, SOM Bagnelle said that the amendments made in April 2014 had included additional questions for CROs to use following comments made by command unit staff during training workshops914 Bagnelle {LFB00122821/5} page 5, paragraph 15. to the effect that finding out how far the caller's flat was from the nearest stairwell would help a CRO decide whether the caller could reach it.915 Reports from command unit training workshops {LFB00122833/1}. It was suggested that a conversation of that kind might cause the caller to consider the layout of the property and realise that escape was possible916 Report from command unit training workshops {LFB00122833/1}. and that a prompt might be included in the RIF to that effect.917 Report from command unit training workshops {LFB00122833/2}.
121¶78.87 Despite that, when they revised the RIF for Operators in April 2014 neither SOM Sharp nor SOM Bagnelle included a prompt of that kind.918 RIF for Operators approved on 3 April 2014 {LFB00003542}. Moreover, it is reasonably clear that the comments from the workshops did not cause either of them to consider whether guidance on assessing the safety of escape routes, beyond the distance to the stairwell, should be included.
¶78.88 The failure to include such guidance was significant because, as the chairman found in the Phase 1 report, CROs failed properly to assess escape routes on the night of the Grenfell Tower fire and advised callers to stay put, even though they may not in fact have been trapped, with the result that some callers may have stayed in their flats when they could have escaped to safety.919 Phase 1 Report Volume IV, paragraph 29.54.c and paragraph 29.60.
¶78.89 The gap analysis drew attention to the warnings in both FSC 10-93 and 'Keeping People Safe' about forming an emotional bond with a caller and providing false reassurance.920 Gap Analysis {LFB00004750/10-11}. It identified that the training of CROs encouraged the creation of a strong attachment between the caller and the CRO and that it recommended using reassuring phrases that might promote a false sense of security.921 Gap Analysis {LFB00004750/11}. Accordingly, the gap analysis recommended that training be changed in those respects.922 Gap Analysis {LFB00004750/11}.
¶78.90 SOM Smith used the findings of the gap analysis to revise the RIFs,923 Smith {Day202/105:22-25}. but despite that, the revised RIF for Operators she approved on 23 February 2011, like PN539, actively encouraged CROs to reassure the caller.924 RIF for Operators approved on 23 February 2011 {LFB00121240/17}. It suggested the use of phrases such as "the firefighters are on the way" and "the firefighters know where you are".925 RIF for Operators approved on 23 February 2011 {LFB00121240/17}. However, the RIF included no warning to the CROs against providing false reassurance nor did it make it clear that such statements must be made only if based on information received from the incident ground.926 RIF for Operators approved on 23 February 2011 {LFB00121240/17}.
122¶78.91 On 3 January 2011, SOM Smith had emailed AOM Bonnett and AOM Suarez with a draft of the revised RIF for Operators.927 Email from SOM Smith to AOM Bennett and AOM Suarez copying in POM Hayward on 3 January 2011 {LFB00033220}. Anticipating the concerns of the Lakanal House Board that it did not appear in national guidance, she had removed the word "bonding".928 Email from SOM Smith to AOM Bennett and AOM Suarez copying in POM Hayward on 3 January 2011 {LFB00033220/1}. It is evident, therefore, that SOM Smith had the gap analysis and national guidance in mind when she was revising the RIF.929 See also Smith {LFB00121219/16} page 16, paragraph 39. In those circumstances, it is hard to understand why she did not include the explicit warning against providing a false sense of security or why she felt it was sufficient to remove only the word "bonding" from the RIF and not the associated statements which had been designed to reassure and create a bond with the caller.930 Draft RIF for Operators dated 16 November 2010 as edited by SOM Smith {LFB00083530/15}.
¶78.92 SOM Smith said she had not included a warning against providing false reassurance because it was guidance on what should be done rather than what should not be done, so it had not occurred to her or the Operational Support Team to include it.931 Smith {Day203/78:10-24}. Even if that were right, however, it presented no bar to including positive guidance in the RIF that a CRO should provide reassurance to callers only if it were based on information received from the incident ground. The suggestion by SOM Smith that it was a matter covered in training932 Smith {Day203/78:22}-{Day203/79:2}. placed too much reliance on training and ignored, or at least underestimated, the importance of ensuring that the RIFs stated accurately and comprehensively the correct approach to handling fire survival guidance calls in accordance with national guidance.
¶78.93 The work on revising the RIFs should have included a comparison with the guidance contained in FSC 10-93 and 'Keeping People Safe' in order to ensure that they were compatible and that nothing had been omitted. However, that was not done and all the later versions of the RIFs suffered from the same defect.933 RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}; RIF for Operators approved on 3 April 2014 {LFB00003542}; RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}. Again, that was significant because CROs invariably told callers on the night of the Grenfell Tower fire that firefighters were on their way without having a sound basis for doing so. The tragic result was that some callers remained in their flats despite the fact that escape may have remained possible.934 Phase 1 Report Volume IV, paragraph 29.54.c.
¶78.94 SOM Smith and SM Utting were together responsible for drafting PN155 (which later became PN790), the policy on fire survival guidance calls.935 See, for example, email from SOM Smith to SM Utting on 23 January 2011 {LFB00028301}; Email from SOM Smith to POM Hayward on 24 January 2011 {LFB00058020}; Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/128:20}-{Day203/129:7}. The draft version of PN155 dated 10 February 2011 included a warning that in exceptional circumstances the incident commander might tell the control room to advise callers seeking fire survival guidance to do their best to leave their properties.936 Draft version of PN155 dated 10 February 2011 {LFB00083447/4} paragraph 6.6. SOM Smith said that she had recommended the inclusion of that paragraph, although she had not been responsible for drafting it.937 Smith {LFB00121219/26} page 26, paragraph 69; Smith {Day203/91:4}-{Day203/92:12}. The wording suggests that the incident commander was responsible for any decision to revoke "stay put" advice. SOM Smith, however, said that she had it in mind that the decision would be made jointly by the control room and the incident commander.938 Smith {Day203/92:22}-{Day203/93:12}. Indeed, in its final form PN790 stated that the decision would be made by agreement between the incident commander and the officer in charge of the control room.939 PN790 issued on 23 February 2012 and reviewed as current on 17 April 2014 {LFB00001257/5} paragraph 8.7.
123¶78.95 SOM Smith does not appear to have given any thought to what might constitute "exceptional circumstances" sufficient to justify the revocation of "stay put" advice.940 Smith {Day203/94:19}-{Day203/95:7}. Nor did she consider providing guidance, whether to the CROs handling fire survival guidance calls or those supervising them, on what information to look out for or gather in order to help decide whether exceptional circumstances requiring an evacuation existed.941 Smith {Day203/94:19}-{Day203/95:7}. Nor, it appears, did POM Hayward,942 Hayward {Day199/220:8-21}. with the result that no such guidance was included in the RIFs.
¶78.96 Perhaps more importantly, SOM Smith did not consider including in the RIFs guidance about what a CRO should tell a caller if the decision had been made to revoke the "stay put" advice.943 Smith {Day203/96:9-16}. SOM Smith said that had been because the advice would differ depending on the particular circumstances, so that, in effect, it could not be the subject of generic guidance.944 Smith {Day203/96:17}-{Day203/97:6}. However, she also said that they did not think that such extreme circumstances were likely to occur.945 Smith {Day203/97:20-25}; Smith {MET00080606/13}. POM Hayward said much the same,946 Hayward {Day199/221:10-23}. but their position makes little sense, given that the policy specifically envisaged that the "stay put" advice might need to be revoked. It is also regrettable, given what was said about it in GRA 3.2,947 GRA 3.2 {LFB00001255/19}. which AC Brown unfortunately failed to pass on to POM Hayward or SOM Smith.
¶78.97 On 13 April 2011, a draft of PN155 was sent to all Assistant Commissioners, including AC Brown, with a request that they assess its effect on their respective departments.948 Email from Michele Kunneke to all ACs on 13 April 2011 {LFB00033332/1}. AC Brown thought that CROs would need guidance on the implementation of the provision relating to the revocation of "stay put" advice,949 Brown {Day206/120:9-22}. in the form of policy, RIFs and training, but he did not consider what form that guidance should take.950 Brown {Day206/120:9}-{Day206/121:4} He assumed that those working on the policy and the RIFs would do that, but it is clear, not least from the absence of any guidance, that he did not take steps to ensure that it was done.951 Brown {Day206/121:2-4}
¶78.98 The failure to include guidance of that kind in the RIFs was significant because, as the chairman found in the Phase 1 report, on the night of the Grenfell Tower fire SOM Smith and DAC Fenton had to make the difficult decision to revoke the "stay put" advice without the benefit of any established guidance. Moreover, many CROs struggled to deliver clear advice to callers that they must leave the building.952 Phase 1 Report Volume IV, paragraph 29.99
124Letter to DCLG about handling fire survival guidance calls
¶78.99 Pre-inquest action 13 was to draft a letter to DCLG seeking clarification of the national guidance on handling fire survival guidance calls in order to ensure a consistent approach among fire and rescue services.953 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/15}. The letter was also intended to recommend a review of national guidance on the subject.954 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/15}.
¶78.100 By April 2010 POM Hayward and SOM Smith had produced a draft letter to DCLG.955 Hayward {Day199/194:8-11}; Smith {LFB00121219/10} page 10, paragraph 24. However, on 20 April 2011 the Lakanal House Board decided not to pursue the matter until the Lakanal Control Report had been completed.956 Minutes of Lakanal House Board meeting on 20 April 2011 {LFB00084035/1} item 4.4. Notwithstanding that decision, on 20 November 2011, after the letter had been reviewed by the LFB legal team, POM Hayward asked for it to be sent to DCLG.957 Minutes of Lakanal House Board meeting on 30 November 2011 {LFB00084038/2} item 8.1. On 12 December 2011, Commissioner Dobson confirmed that it should be sent and asked for a copy to sign.958 Minutes of the Lakanal House Board meeting on 12 December 2011 {LFB00084039/2} item 8.1; Dobson {Day211/143:19}-{Day211/144:1}.
¶78.101 On 3 February 2012, a draft of the letter dated 23 December 2011 was sent by Linda Armstrong, Deputy Head of Legal Service, by email to Sue Marshall, Commissioner Dobson's secretary, for final approval and signature by the Commissioner with a request that it be addressed to Sir Ken Knight, then Chief Fire and Rescue Adviser.959 Email from Linda Armstrong to Sue Marshall copying Commissioner Dobson and DAC Cutbill dated 3 February 2012 {LFB00100551}. Draft Letter to DCLG dated 23 December 2011 {LFB00004744}. There is another version of the letter dated 3 February 2012 addressed to Sir Ken Knight.960 Letter from Ron Dobson to Sir Ken Knight dated 3 February 2012 {LFB00004728}.
¶78.102 The letter suggested that the relationship between FSC 10-93 and FSC 54-04 should be reviewed and that in any review of the provision of fire survival guidance there were seven areas to which particular consideration should be given. They included better guidance on engaging with callers when assessing their situation and exploring possible means of protection and escape, continual reassessment of changing conditions and the caller's physical and mental condition, guidance on effective communications between the control room and the incident ground and training on the role of supervisors in the control room.961 Letter from Ron Dobson to Sir Ken Knight dated 3 February 2012 {LFB00004728}.
¶78.103 SOM Smith said that she had felt that national guidance needed to be revised in that way because of the LFB's experience at the Lakanal House fire and because a lot had changed since FSC 10-93 had been published.962 Smith {Day202/143:17-24}. She had felt that it was necessary that someone with that degree of experience should investigate whether there were new practices that could help control room staff.963 Smith {Day 202/144:1-11}. She had assumed that other fire and rescue services might make the same mistakes as the LFB had made at the Lakanal House fire and would benefit from what the LFB had learnt.964 Smith {Day202/144:22}-{Day202/144:3}.
125¶78.104 Despite SOM Smith's view and the decision in December 2011 to send the letter to DCLG, it was not in fact sent. A later decision was made in July 2012, apparently by DC Dexter, to defer once again sending the letter until work on the Lakanal Control Report had been completed.965 Minutes of the Lakanal House Board meeting on 2 July 2012 {LFB00084043/1} item 5.1; Minutes of Lakanal House Board meeting on 7 September 2012 {LFB00084044/1} item 4.1; Minutes of Lakanal House Board meeting dated 17 October 2012 {LFB00084045/2} item 6.1; Hayward {Day199/194:17-25}.
¶78.105 The version of the Lakanal Control Report dated November 2012 was unequivocal in recommending that Commissioner Dobson should write to DCLG to prompt a review of national guidance on handling fire survival guidance calls.966 Lakanal Control Report dated November 2012 {HOM00001124/51} paragraph 303. However, despite that recommendation, Commissioner Dobson decided on 19 November 2012 not to send the letter.967 Minutes of the Lakanal House Board meeting on 19 November 2012 {LFB00084046/1} item 6.1. His decision was reconsidered at the meeting of the board on 14 December 2012, however, when he decided that it would be reviewed after the conclusion of the Lakanal House inquests.968 Minutes of the Lakanal House Board meeting on 14 December 2012 {LFB00040033/1}; Dobson {Day211/144:23}- {Day211/145:1}. Commissioner Dobson thought that decision had been discussed at the Lakanal House Board.969 Dobson {Day211/145:2-6}. He said that he had been persuaded that it was better to wait for the coroner's conclusions.970 Dobson {Day211/145:7-15}. However, in September 2013, he decided that the letter was no longer required and had been dealt with by the outcomes of the inquest.971 Minutes of Lakanal House Board meeting on 30 September 2013 {LFB00050644/1} item 5.1. He said that he had taken that decision on the advice of the Lakanal House Board.972 Dobson {Day211/148:15-19}.
¶78.106 However, the coroner's rule 43 letters did not deal with the matters raised in the draft letter to the DCLG,973 There is nothing dealing with those issues in the coroner's rule 43 letter to DCLG dated 28 March 2013 {CLG00000401} nor in her rule 43 letter to the LFB dated 28 March 2013 {LFB00032158}. so it is not clear why Commissioner Dobson thought that the matters it raised had been dealt with by the outcome of the inquests. The consequence of the decision not to send the letter in September 2013 was that, almost three and half years after the pre-inquest action had been raised and the letter to DCLG had been drafted, it had still not been sent. As a result, the respects in which national guidance on the handling of fire survival guidance calls needed to be improved were not considered by DCLG. It also meant that the recommendation in the Lakanal Control Report was not carried out. The coroner was not informed of that, an omission which Commissioner Dobson described as an oversight.974 Dobson {Day211/148:3}-{Day211/149:5}.
¶78.107 In his review dated 4 January 2013 GM Lindridge found that the gap analysis had identified areas in which national guidance could be improved which had not been incorporated into LFB policy.975 GM Lindridge's review dated 4 January 2013 {LFB00085854/5}. DC Dexter asked why that had not been done. AC Brown said that all the suggestions had been adopted where relevant.976 GM Lindridge's review dated 4 January 2013 with DC Dexter and AC Brown's comments {LFB00085854/5}. However, AC Brown's confidence was misplaced because not all GM Lindridge's recommendations for improvement in national guidance had been considered and adopted. In particular, the gap analysis had recommended that national guidance be improved to emphasise the need for continual reassessment of the caller's circumstances,977 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/14}; {HOM00001125/17}. but PN539 did not emphasise that, although AC Brown thought it was implicit.978 Brown {Day206/99:6-13}.
126¶78.108 AC Brown said that when AC Chandler had returned to work he had asked him to review the audit and satisfy himself that everything had been done.979 Brown {Day206/100:4-12}. It is clear, however, from the terms of AC Brown's instructions that he did not ask AC Chandler to check whether all the recommendations to improve national guidance had been covered by LFB policy.980 Email from AC Brown to AC Chandler on 4 April 2013 {LFB00028942/1}. It is equally clear that AC Chandler did not deal with it in his response.981 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701}. POM Hayward could not recall whether any other action had been taken in response to the recommendation.982 Hayward {Day199/200:2-5}.
¶78.109 We have come to the conclusion that no action was taken in response to that particular recommendation and that as a result, an opportunity was missed to correct some of the defects in PN539, including the absence of the important emphasis on the need for continual reassessment of the caller's situation.
Handling multiple fire survival guidance calls
¶78.110 In the Phase 1 report the chairman identified the need to examine whether, when, and to what extent the LFB was aware of the deficiencies that existed in its policy and training for fires that gave rise to a large number of concurrent fire survival guidance calls.983 Phase 1 Report Volume IV, paragraph 29.42. He found that PN539 was defective, in part because it did not recognise the important fact that, because a fire survival guidance call (as defined) requires the continued presence of a CRO on the line, the number of calls that could be handled concurrently could not exceed the number of CROs available.984 Phase 1 Report Volume IV, paragraph 29.45(b).
¶78.111 The definition of a fire survival guidance call in PN539 was introduced after the Lakanal House fire because the LFB had wanted something more robust than had previously existed.985 Smith {Day202/153:4} – {Day202/154:25}. It was formulated by those working in the control room, together with DACs Tim Cutbill and Tom Davies, and was agreed by the Lakanal House Board.986 Smith {Day202/154:7-13}. It did not come from national guidance.987 Smith {Day202/154:14-15}. SOM Smith said that people had realised at the time that the number of simultaneous fire survival guidance calls could not exceed the number of CROs and supervisors available, but that in the past the control room had never received more fire survival guidance calls than it could handle.988 Smith {Day202/156:18} – {Day202/157:12}.
¶78.112 In PN539 a fire survival guidance call is defined as
"a call to Brigade Control where the caller believes that they are unable to leave their premises due to the effects of fire, and where the Control Room Officer remains on the line providing appropriate advice until either the caller is able to leave by their own means, is rescued by the Fire brigade or the line is cleared".
¶78.113 It became apparent during the evidence, particularly that of SOM Smith, that the definition is open to different interpretations,989 Smith {Day202/183:18} – {Day202/185:22}. since it depends on an exercise of judgement by the relevant CRO about the content of the call.990 Smith {Day202/183:18} – {Day202/185:22}. As a result, the precise number of fire survival guidance calls reported at any one incident could itself be a matter of debate.991 For example, see Smith {Day202/183:18} – {Day202/185:22}. For example, evidence about the Marriott Hotel fire on 11 November 2010, a ten-pump fire in a hotel and private residential block of 32 floors in Poplar, East London,992 Daily Bulletin {LFB00109347/3}. variously suggested that the control room had received between four and seventeen fire survival guidance calls.993 SOM Smith reported that four fire survival guidance calls had been received {Day202/185:14-22}; the 'End of Incident Report' suggested that approximately eight fire survival guidance calls had been received because of the number of fire survival guidance messages transferred from the control room to the incident ground {LFB00123671/3-8}. The figure of 17 fire survival guidance calls was contained in a comment to a draft of PN155 at paragraph 6.2 {LFB00109485/3}. The LFB's contemporaneous documentary evidence from the Adair Tower fire on 31 October 2015, an eight-pump fire in a high-rise residential block of flats located in the Royal Borough of Kensington and Chelsea, suggested that nine fire survival guidance calls had been received,994 Debrief proforma for Adair Tower {LFB00035092/3}; FSG Database {LFB00031757} rows 20 to 28. but SOM Smith told us that when she had listened to the calls before giving evidence, she had reached the conclusion that only six could properly be described as fire survival guidance calls.995 Smith {Day202/201:1-20}.
127¶78.114 It is difficult to understand how the identification of a fire survival guidance call could have remained a source of debate within the LFB after the Lakanal House fire, particularly when handling three fire survival guidance calls concurrently was a complex and intense experience. If the LFB could not consistently and accurately identify a fire survival guidance call, it could not tell how many had been generated by any particular incident, making it impossible to draw reliable conclusions or plan for future incidents. We have therefore sought to examine what lessons for handling fire survival guidance calls the LFB learned from the Lakanal House fire, which gave rise to five fire survival guidance calls, three of which were being dealt with at the same time.996 Lakanal Control Report {HOM00001124/35-37}, Table 4, rows 4, 28, 31, 38 & 43.
¶78.115 Before the Grenfell Tower fire, there had been a consensus among senior managers that the Lakanal House fire had been an exceptional event and that under normal circumstances the control room was unlikely to receive more than two or three fire survival guidance calls from any incident.997 Hayward {LFB00121176/16} page 16, paragraph 66; Bagnelle {LFB00122821/2} page 2, paragraph 6 and {LFB00122821/6} page 6, paragraph 19. Although SOM Smith initially said that the expression "multiple fire survival guidance calls" was not used within the LFB or nationally,998 Smith {LFB00121219/12-13} pages 12-13, paragraph 29. it is clear that the LFB had made preparations for the receipt of two simultaneous calls, which could be viewed as "multiple" fire survival guidance calls.999 Smith {Day202/162:5} – {Day202/163:12}.
¶78.116 One striking aspect of the senior managers' evidence was their common belief that the control room's experience with the Lakanal House fire would not be repeated and that it was highly unlikely that more than three fire survival guidance calls would ever be received during one incident.1000 Hayward {LFB00121176/16} page 16, paragraph 66; Bagnelle {LFB00122821/2} page 2, paragraph 6 and {LFB00122821/6} page 6, paragraph 19; Smith {LFB00121219/17} page 17, paragraph 43. That belief should have been questioned following a number of major fires attended by the LFB which involved a significant number of fire survival guidance calls, and certainly more than two or three.
¶78.117 The first such incident was the fire at the Marriott Hotel in Poplar, London, on 11 November 2010.1001 Smith {Day202/183:18-24}. SOM Smith was in attendance that night as control duty manager.1002 Smith {Day202/183:18-24}. On that occasion the control room received between four and seventeen fire survival guidance calls (depending on how one defines them) during the course of the incident, which led to seven or eight messages being passed to the incident ground about persons trapped in their flats.1003 SOM Smith reported that four fire survival guidance calls had been received {Day202/185:14-22}; the end of incident report suggested that between seven and eight fire survival guidance calls had been received {LFB00123671}; the figure of 17 fire survival guidance calls was recounted in a comment to a draft of PN155 at paragraph 6.2 {LFB00109485/3}. SOM Smith thought that there had been two concurrent fire survival guidance calls which had lasted for 45 minutes and one hour respectively.1004 {Day202/185:14-22}. After the incident, AC Hickmott sent an email to Commissioner Dobson,
128¶Deputy Commissioner Dexter, AC Cowup, AC Brown and POM Hayward, in which he described the particularly challenging nature of many of the fire survival guidance calls, some of which had lasted for more than an hour.1005 Email from Andy Hickmott to Scott Hayward, Dave Brown, Peter Cowup, Rita Dexter and Ron Dobson titled "FW: Daily Bulletin.12-11-10.doc" dated 12 November 2010 {LFB00110785/2}. By contrast, AC Brown saw the incident as little more than a normal, if busy, day,1006 Brown {Day206/126:9-16}. a remark which we consider revealed a degree of insouciance about the magnitude of the problem.
¶78.118 Although the incident generated more fire survival guidance calls than the Lakanal House fire, their number did not prompt any discussion about the control room's capacity to handle multiple fire survival guidance calls.1007 Brown {Day206/126:1-7}. According to AC Brown, that was because the control room had handled them very well.1008 Brown {Day206/126:8-9}. Be that as it may, it did not prompt any consideration of the need to plan or train for an incident which generated eight simultaneous fire survival guidance calls.1009 Brown {Day206/126:17} – {Day206/127:11}. According to AC Brown that was because the LFB was already taking the steps identified in the Lakanal Control report by developing PN790 and had started giving training on handling fire survival guidance calls.1010 Brown {Day206/126:17} – {Day206/127:11}.
¶78.119 On 16 June 2011, the LFB carried out an eight-pump exercise called the Heygate Challenge.1011 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. It was developed to test the proposed amendments to the high-rise firefighting policy and the new draft policy on fire survival guidance calls.1012 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. POM Hayward and SOM Smith representing the control room were involved as observers and facilitators.1013 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. As part of the exercise the control room simulated a live incident, allocating specific pumps and passing information from mock fire survival guidance calls to the incident ground.1014 Smith {Day202/171:3-10}; Hayward {Day199/210:11-20}. The exercise included four fire survival guidance calls, although it is unclear whether they were concurrent.1015 'Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark' {LFB00033384/11}; Smith {Day202/172:1-18}. It is unclear why only four fire survival guidance calls were chosen, given that five calls had been received at the Lakanal House fire.1016 Smith {Day202/176:23} – {Day202/177:10}; Hayward {Day199/212:21} – {Day199/214:7}.
¶78.120 After the exercise, a debriefing meeting was held.1017 Minutes of debrief meeting {LFB00056628}. SOM Smith could not recall attending it or being involved in any discussion or meeting after the exercise.1018 Smith {Day202/173:20} – {Day202/173:24}; Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark' {LFB00033384/11}. Although POM Hayward thought that he had attended the meeting, the minutes do not record any contribution from the control room.1019 Hayward {Day199/212:7-12}; Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark {LFB00033384/10}; Minutes of debrief meeting {LFB00056628}. Later reports from the command units recorded a consensus that the form used by staff in the command units had worked adequately for four flats as simulated in the exercise, but that the process would have been unmanageable for 20 or more calls, as one command unit had experienced at a previous incident.1020 Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark {LFB00033384/10-11}. No witness was able to identify that incident.
129¶Further analysis noted that recording fire survival guidance calls was hard enough with four flats involved, but would be almost impossible if 60 flats were involved.1021 Minutes of debrief meeting {LFB00056628/4}.
¶78.121 Although the Heygate Challenge involved only four fire survival guidance calls, the reports on that exercise show that the LFB was aware that multiple fire survival calls could arise from a single incident and that in those circumstances an efficient flow of information to the command units could not be maintained. Despite that, no attempt was made to plan for an incident that could generate as many as 60 fire survival guidance calls,1022 Hayward {Day199/215:12-21}. probably because the LFB had never experienced an incident involving 60 flats.1023 Hayward {Day199/215:12-21}. At all events, it seems clear that there was no discussion among those responsible for the operation of the control room about how it would handle more than four concurrent fire survival guidance calls. It is also clear that by mid-2011 a picture was developing that showed that incidents could give rise to more (and conceivably many more) than two or three calls of that kind.
¶78.122 As we noted earlier, during 2011, PN155 was being drafted predominantly by SM Utting and SOM Joanne Smith.1024 Utting {Day198/103:10-25}; Smith {LFB00121219/26} page 26, paragraph 69. Paragraph 7.10 of one draft specifically contemplated that the control room might receive multiple fire survival guidance calls, because it suggested that the incident commander should consider calling for an additional command unit to help managing a large number of such calls .1025 Draft PN155 issue date 10 February 2011 {LFB00111471/5} However, there was no consensus between SM Utting and SOM Smith, or indeed between other senior managers of the LFB, on what a large number of fire survival guidance calls might mean or about how many fire survival guidance calls might be generated by any one incident.1026 Brown {Day206/122:23} – {Day206/123:11}; Smith {Day202/198:3} – {Day202/199:7}; Patrick Utting could not recall having discussed or even having considered the possibility of more than 5 fire survival guidance calls being generated by a single incident or how the control room would manage such an occurrence: Utting {Day198/118:17} – {Day198/119:18}. It is unclear why no consensus had been reached on that, given that the policy was specifically directed to handling multiple fire survival guidance calls, or why officers had up to five calls in mind when it had already become apparent from the Marriott hotel fire and the Heygate Challenge that it was possible for a single incident to generate many more calls.
¶78.123 In February 2014, GRA 3.2 was published.1027 GRA 3.2 {LFB00001255/3}. It included a section entitled "Fire Survival Guidance" which emphasised that numerous fire survival guidance calls could be received during a single high-rise incident.1028 GRA 3.2 {LFB00001255/30}. The guidance was relevant to the control room's ability to handle numerous fire survival guidance calls, but none of those responsible for its operation appears to have been asked to review GRA 3.2 or even to have been consulted about its contents. Although it contained advice on handling fire survival guidance calls, neither POM Hayward nor SOM Smith had been aware of it before the Inquiry brought it to their attention because of its focus on operational matters.1029 Smith {Day202/199:8-19} and {Day203/20:3-8}; Hayward {Day200/53:13} – {Day200/54:22}. The result was that there was no discussion about how the control room would handle multiple fire survival guidance calls as GRA 3.2 contemplated.1030 Smith {Day202/199:20} – {Day202/200:3}; Hayward {Day200/53:13} – {Day200/54:22}.
130¶78.124 During Phase 1 the chairman heard evidence about a tactical decision exercise training programme involving seven fire survival guidance calls that SM Peter Johnson had devised in 2014. Its purpose was to ascertain the maximum number of fire survival guidance calls that the control room and incident ground could handle satisfactorily at any one time. He also expected it to demonstrate that the procedures for handling fire survival guidance calls were inadequate.1031 Phase 1 Report Volume IV, paragraph 29.40. In Phase 2, we have investigated why the LFB did not proceed with SM Johnson's programme. His exercise was sent to borough commander Terence Harrington on 27 February 2014 and presented to the fire survival guidance policy group on 12 March 2014.1032 Harrington {LFB00102245/8} page 8, paragraph 18; Withers {LFB00084123/5} page 5, paragraph 16; Minutes of Fire Survival Guidance Meeting on 12 March 2014 {LFB00084124}. At that time, GM Harrington was trying to develop a practical exercise involving the structured delivery of training to impart knowledge, clarify roles and responsibilities and better understand the complexities of handling fire survival guidance calls arising from a small-scale incident that escalates to something larger.1033 Harrington {LFB00102245/12} page 12, paragraph 31. He decided that SM Johnson's training programme did not meet that aim and it was therefore not implemented.1034 Harrington {LFB00102245/12} page 12, paragraph 31. However, even though SM Johnson's proposal was not taken any further, it demonstrates that there was some recognition in 2014 that more than four or five concurrent fire survival guidance calls might arise from a single incident, that the systems might not be capable of managing them and that preparations should be made to deal with them. Unfortunately, that view was neither shared nor discussed more widely within the LFB.1035 Withers {LFB00084123/5} page 5, paragraph 16.
¶78.125 The last significant incident before the Grenfell Tower fire which gave rise to fire survival guidance calls was an eight-pump fire at Adair Tower on 31 October 2015.1036 FSG Database {LFB00031757}. Between six and nine fire survival guidance calls were received between 08.54 and 09.08, together with 15 other calls.1037 Debrief proforma for Adair Tower {LFB00035092/5}; FSG Database {LFB00031757}; Smith {Day202/201:1-20}. The incident made it clear that the control room could receive more than two or three fire survival guidance calls during a single high-rise fire. Although SOM Smith described the incident as manageable,1038 Smith {Day202/205:6-18}. she was able to shed little light on why senior officers continued to believe that a single incident would be unlikely to give rise to more than two or three fire survival guidance calls and that more than five such calls was unthinkable.
¶78.126 Even though the control room had received an exceptional number of fire survival guidance calls during the Adair Tower fire, the incident did not prompt any consideration of how so many calls should be managed.1039 Smith {Day202/206:18} – {Day202/207:14}. The FSG Database did not record any lessons to be learnt or systems to be reviewed {LFB00031757}. The Incident Debrief form did not record any learning about fire survival guidance management {LFB00035092}. The IMP report for the incident did not record any learning about fire survival guidance management {MET00080621}. It was not just the number of calls that should have prompted a review. A novel practice of recording information relating to calls on a whiteboard, which was not provided for in policy, was adopted at that incident.1040 {LFB00035092/5}. It should be noted that on 20 December 2016, following a command unit training exercise, Liz Hymns expressed concern that a whiteboard had not been set up for managing multiple fire survival guidance calls to enable the control room to manage the information, even though she considered that to be standard practice: {LFB00052219/1}. More importantly, most of the calls were taken by CROs who had less than two years' experience and for some it was their first fire survival guidance call. The incident should, therefore, have prompted careful consideration about how best to manage multiple fire survival guidance calls.
131¶78.127 Regrettably, we have come to the conclusion that despite all the indications that a large number of calls seeking fire survival guidance could be generated by a single incident, particularly one involving a large or high-rise residential building, the LFB failed to recognise that possibility and therefore failed to take any steps to prepare for it by training its staff or putting in place systems and procedures to respond to such an eventuality. The result was that when faced with an unprecedented number of callers from Grenfell Tower seeking fire survival guidance, the control room and those at the fireground were unable to rely on tried and tested systems and were forced to resort to various improvised methods of varying reliability to handle the large amount of information generated. That represents a major failing on the part of the LFB.
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