Chapter 80: Communications

Chapter 80: Communications

¶80.1 In his Phase 1 report, the chairman found that from the earliest stages of the incident the deployment of firefighters inside the tower was hampered by generally ineffective communications, that communication difficulties significantly limited the efficiency of search and rescue operations^15321532 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.130. and that it was well known within the LFB that BARIE sets performed badly in concrete high-rise buildings. He concluded that greater efforts should therefore have been made to establish and maintain effective communications inside the tower on the night.^15331533 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.131. In this phase of the Inquiry we have examined the communication equipment used by the LFB in order to identify the source of the problems and have considered whether sufficient steps were taken to solve them.

¶80.2 A general description of the communication equipment used by the LFB on 14 June 2017 can be found in paragraphs 7.66–7.69 of the Phase 1 report, but for the purposes of this chapter it is necessary to describe it in a little more detail.

Overview

¶80.3 At the time of the Grenfell Tower fire the LFB relied on radio for communication between the control room and the fireground and between firefighters, both at the fireground and more widely. It used two kinds of radio equipment:^15341534 Christopher Johnson {Day189/8:14}. ultra-high frequency (UHF) analogue radios and Airwave digital radios. ("Airwave" is the name of the network and of the network services provider.) In broad terms, UHF radios were used for localised, personal, operational use, principally on the fireground; Airwave radios were used for tactical functions, including communication with the control room and other emergency services.

¶80.4 The primary method of using UHF radio was by operation of a handset which acted as both transmitter and receiver. In addition, however, breathing apparatus radio interface equipment (BARIE) was used with the helmets and masks of many breathing apparatus sets.

¶80.5 UHF radio communications can be enhanced by radio repeaters, which receive and re‑broadcast a radio signal, and by "leaky feeders", which are cables that connect radio repeaters to form a series while simultaneously 'leaking' the radio signal to improve its reception between repeaters.^15351535 Christopher Johnson {Day189/45:1-11}; {Day189/45:12-25}; Policy 700 {LFB00001762}. Repeaters can be portable or fixed in buildings, tunnels and similar environments, or on LFB appliances.

¶80.6 Airwave digital radio, sometimes referred to within the LFB as the "main scheme radio", was also mainly operated using handsets. In addition, however, all LFB appliances contained a fixed digital radio in the vehicle's cab, which allowed crews to use the Airwave system to communicate with the control room and senior officers.

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¶80.7 The central LFB policy on communications was Policy No 488 on Incident Communications.^15361536 {LFB00000736}: this policy was extant at the time of the Grenfell Tower fire. The Inquiry does not have a copy of the policy in place at the time of the Lakanal House fire. It set out the intended uses of each UHF channel as well as the responsibilities of a communications operator and command unit staff. A number of other policies that we do not need to mention here governed the deployment and use of specific items of communication equipment.

Analogue (UHF) radio equipment

¶80.8 The LFB's UHF radios had 10 channels, which were used for the following purposes:^15371537 As summarised in Ellis {LFB00089131/7-9} pages 7-9, paragraph 26. a. Channel 1: the primary incident command and control channel. b. Channel 2: a back-up incident command and control channel, which could be used only with a radio repeater.^15381538 Radio repeaters are explained further below but, in summary, they are items of equipment intended to extend the range of a radio signal.

¶c. Channel 3: a channel used by specific teams for particular activities, for example, organising the supply of water or dealing with fire survival guidance calls.

¶d. Channel 4: a back-up channel, which offered additional capacity, but was not routinely used.

¶e. Channel 5: a back-up channel for communicating with BA wearers, which could be used only with a radio repeater. f. Channel 6: the primary channel for communicating with BA wearers.

¶g. Channel 7: a channel which had previously been used by the police, but had been assigned to the LFB. It provided additional capacity, but was not routinely used.

¶h. Channel 8: another channel made available by the police which provided additional capacity but was not routinely used. It required a radio repeater.

¶i. Channel 10: a channel used by command unit crews for communications relating specifically to their work.

¶j. Channel 11: for communications between the LFB and the Airport Fire Service at Heathrow Airport. This channel was loaded only on to radios at the Heathrow fire station.

¶80.9 UHF radios are intended for use locally, usually within the area of a particular incident. The signals travel a finite distance which, without interruption or interference, is determined primarily by the power of the transmitting handset.^15391539 Christopher Johnson {Day189/9:22}-{Day189/10:1-3}. Professor Chris Johnson, a communications expert retained by the Inquiry, pointed out that the limited and localised range of UHF signals could be used to an organisation's advantage by restricting the number of people who can receive a transmission to a localised team.^15401540 Johnson, Communications Expert Report {CWJ00000119/142} paragraph 6.6.5; Christopher Johnson {Day189/16:1}- {Day189/17:12}. However, that was not a relevant consideration in this case because of the almost complete loss of communications in the tower on the night of the fire.

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¶80.10 The LFB's handheld radios operated at a maximum power of 4 watts, but when transmitting on many channels were limited for historical reasons to 2.3 watts. BARIE sets, on the other hand, operated at only 1 watt. As a result, when crews were operating in the confines of a building, voice communications using BARIE sets might not reach their intended recipients without distortion or interference, or at all.^15411541 Christopher Johnson {Day189/25:14}-{Day189/26:16}.

¶80.11 The LFB deliberately restricted the power of its BARIE sets to make them what is known as "intrinsically safe", that is, of sufficiently low power to minimise the risk of creating a source of ignition when operating in a dangerous environment. Generally speaking, an increase in the power of a radio increases the risk of creating a source of ignition.^15421542 Johnson, Communications Expert Report {CWJ00000119/42} paragraph 3.2.5 - 3.2.13; Christopher Johnson {Day189/26:17}-{Day189/29:4}. For that reason, the LFB was reluctant to allow the use of more powerful radios in BARIE sets, particularly in environments that posed a risk of explosion, such as compartments or tunnels where gas might collect, and certain kinds of industrial premises. However, the need for intrinsic safety is less pressing in some circumstances, for example, when a fire has already started in a residential building. Although even in those circumstances there remains a risk that a radio might cause a gas explosion,^15431543 Reason {Day182/39:18}-{Day182/40:13}; {Day181/204:12}-{Day181/205:9}. the justification for not using intrinsically safe devices is that the risk is lower than in other environments in which flammable gas is likely to be encountered.

¶80.12 For similar reasons, the use of handheld radios by those wearing breathing apparatus was generally prohibited,^15441544 Policy No. 458 {LFB00013039/2} fourth bullet point. The general prohibition may be lifted where BARIE radios are unavailable and, following a risk assessment, the incident commander consents to the use of UHF radios. but there were also practical reasons for not using them, principally the difficulty of operating them when wearing personal protective equipment. Nonetheless, the use of handheld radios was one way of trying to achieve better communications.^15451545 Christopher Johnson {Day189/44:4-20}; Ellis {LFB00089131/7} page 7, paragraph 21. It had therefore become common practice for firefighters wearing breathing apparatus to use their handheld radios without the incident commander's approval and some certainly did so on 14 June 2017.^15461546 Johnson, Communications Expert Report {CWJ00000119/55} paragraph 4.2.7. As each team wearing breathing apparatus had only one BARIE set between them, one member of the team would be obliged to use a handheld radio if they became separated.^15471547 Christopher Johnson {Day189/38:5}-{Day189/39:9}. There was also evidence that the earpieces in BARIE sets frequently became loose or dislodged, thereby preventing effective communication.^15481548 Johnson, Communications Expert Report {CWJ00000119/151} paragraph 6.9.4. In the event, therefore, BARIE sets were not a reliable means of communication in the difficult circumstances confronting firefighters in the tower.

¶80.13 As had become clear to the LFB during its investigations into the Lakanal House fire, the distance over which UHF signals travel is affected by surrounding objects and the built environment. It is common for nearby objects or materials to block, distort or reflect signals, thereby interfering with transmissions. That, in turn, can distort the message received by the recipient or block the signal entirely.^15491549 Johnson, Communications Expert Report {CWJ00000119/43} paragraphs 3.2.15 - 3.2.16; Christopher Johnson {Day189/14:1}-{Day189/15:10}. As a result of the complex interactions between radio signals and objects in the built environment, Professor Johnson was unable to give a reliable estimate of the distance over which either the handheld radios or the BARIE sets would operate effectively in practice.^15501550 Christopher Johnson {Day189/21:5}-{Day189/22:2}. However, he considered that the LFB's estimated range of 500 metres or more using a 4 watt transmitter (assuming that the signals were unobstructed) was plausible.^15511551 Christopher Johnson {Day189/97:1}-{Day189/98:7}; {Day189/100:2-21}. He was unable to estimate the range of signals transmitted at 1 watt (e.g., from a BARIE set), but was of the view that it would be significantly lower.^15521552 Christopher Johnson {Day189/100:2-21}.

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¶80.14 In fact, by 2017 it had been well known for some time that some kinds of construction materials (including metals, thick concrete, insulation, foil-backed materials and energy efficient windows) can interfere significantly with UHF radio signals, particularly if there is an accumulation of obstructions.^15531553 Christopher Johnson {Day189/103:4}-{Day189/104:5}; {Day189/107:10-14}. As a result, UHF signals cannot travel to their full potential range between the floors of a high-rise building,^15541554 Christopher Johnson {Day189/97:1}-{Day189/98:7}. given the distances involved, the materials used in their construction and other forms of obstruction. Those limitations are particularly important when considered against the backdrop of the limited transmission power of BARIE sets and the congestion in radio traffic caused by many users.^15551555 Christopher Johnson {Day189/99:6-20}.

¶80.15 Congestion, which arises when more people attempt to use the system than it can handle at any one time, can affect both analogue and digital systems. In the case of an analogue system, only one person can transmit at a time,^15561556 Johnson, Communications Expert Report {CWJ00000119/181} paragraph 7.4.2. which means that firefighters need to wait for others to complete their transmissions before they can send their own messages. At a large incident there may be a lot of people waiting to send a message, which in turn can delay urgent or critical messages, as happened on 14 June 2017. If one person attempts to interrupt a message in the course of transmission that is likely to interfere with both signals.^15571557 Christopher Johnson {Day189/11:3-20}. Those effects are likely to have been one cause of the communication difficulties experienced in and around the tower on 14 June 2017.

¶80.16 A rudimentary solution to the problem of congestion is to reduce the number of people using any given channel. That reduces the time a user has to wait for an opportunity to transmit, as well as the chances of users interrupting one another and causing signal interference. Using a larger number of channels for different groups of firefighters, or for specific activities,^15581558 In the way that channel 3 was used to relay fire survival guidance information on the night of the fire: Johnson, Communications Expert Report {CWJ00000119/149} paragraph 6.8.9. can go some way towards achieving that aim.

¶80.17 Radio signals can be enhanced by the use of portable radio repeaters and leaky feedercables but both pieces of equipment have a limited power to propagate signals and leaky feeders are typically effective only within sight of the cable,^15591559 Johnson, Communications Expert Report {CWJ00000119/176} paragraph 7.2.4; Christopher Johnson {Day189/51:12}-{Day189/52:19}; Dobson {Day212/45:23}-{Day212/46:4}. which significantly limits the value of deploying them in the stairwell of a high-rise building. Professor Johnson told us that he had seen no evidence to suggest that portable radio repeaters in combination with leaky feeders would restore communications in the majority of high-rise buildings in London.^15601560 Christopher Johnson {Day189/136:1-12}. It should be noted that the Inquiry is not concerned with and has not considered the advantages of leaky feeders that are embedded within a building.

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¶80.18 Commissioner Dobson and AC Reason said that the LFB resorted primarily to radio repeaters and leaky feeders as the fallback mechanism to combat difficulties with communications because they were understood to be effective and were the best solution available at the time of the Grenfell Tower fire.^15611561 Dobson {Day212/45:1}-{Day212/46:11}; Reason {Day182/24:16-22}; {Day182/50:3-14}. However, that approach failed to take account of the following points: a. First, the equipment is not intrinsically safe,^15621562 Christopher Johnson {Day189/54:14-25}. so its use was inconsistent with the use

of intrinsically safe radios in the BARIE sets. There is no evidence that firefighters were warned about that.

¶b. Secondly, the equipment is time-consuming to install and is therefore likely to be deployed only after communications have deteriorated significantly. Furthermore, the cables can pose a trip hazard to firefighters and residents.^15631563 Lakanal House Inquest – Day 42 Transcript {CWJ00000010/73-74}. Commissioner Dobson accepted that neither radio repeaters nor leaky feeders would be an incident commander's first choice.

¶c. Thirdly, radio repeaters and leaky feeders can only be as effective as their deployment. The LFB provided training on the use of this equipment to Extended Duration Breathing Apparatus (EDBA) wearers only,^15641564 Johnson, Communications Expert Report {CWJ00000119/193}. leaving the majority of firefighters with insufficient training on how to use it.^15651565 Training packages on communications were developed following the Lakanal House fire as part of TCAP 0039, but were not released before the Grenfell Tower fire. In any event, those packages gave only a description of the operation and set up of repeaters and leaky feeders and did not distinguish between the two {LFB00122846}; {LFB00122844}. That failure was exemplified by the inability of crews at the Grenfell Tower fire to identify the correct equipment. As a result of their lack of training, crews mistook portable telemetry repeaters for radio repeaters.^15661566 Ashman {LFB00102269/3} page 3, paragraphs 11-12.

¶d. Finally, as stated earlier in this chapter, radio repeaters and leaky feeders operated on dedicated channels. Deploying radio repeaters and leaky feeders therefore required a change of channel. At the time of the Grenfell Tower fire, the LFB had no policy, training or strategy in place for co-ordinating a change of that kind.

¶80.19 Although it was reasonable for the LFB to use radio repeaters and leaky feeders to alleviate difficulties with communications, given the limitations outlined above, it was not reasonable for it to rely on such equipment as its primary fallback mechanism for solving the problem of poor communications when operating in a high-rise residential building.

Digital radio equipment

¶80.20 In Phase 1, there was evidence to suggest that at the Grenfell Tower fire digital radios had performed to a higher standard or provided better coverage than UHF radios. Digital devices essentially encode soundwaves into digital values and, in doing so, enable the signal to be encrypted.^15671567 Christopher Johnson {Day189/8:9-23}. Digital radios can operate in two modes: direct mode (which is much like UHF radio in that the user communicates directly with another handset) and trunk mode, in which the radio transmission is sent via a base station, similar to a mobile telephone signal. When communicating in trunk mode, users join Airwave talk groups (equivalent to channels). The national Airwave network hosts a large number of talk groups; a document produced by the LFB in 2015 indicates that at that time it had access to about 70 talk groups but used only a handful at any given time.^15681568 {LFB00084685/25} paragraph 85; Reason {Day182/87:7-15}. Because of their national coverage, talk groups can be assigned to a specific incident, location or activity, which provides an incident ground with more flexibility than the UHF system of separate channels.^15691569 Christopher Johnson {Day189/177:18-23}; {LFB00033375/2}.

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¶80.21 Professor Johnson attributed the superior coverage of Airwave radios to their national, trunk mode operation,^15701570 Christopher Johnson {Day189/57:11-23}; Christopher Johnson {Day189/58:9-12}. but it is important to note that, as in the case of analogue radio, digital radio signals are susceptible to blocking, degradation and interference.^15711571 Christopher Johnson {Day189/58:14}-{Day189/59:4}. Although it is possible to enhance digital signals with repeaters,^15721572 Christopher Johnson {Day189/59:5-10}. we have not seen any evidence that the LFB used, or contemplated using, such equipment in conjunction with digital radios.

¶80.22 Digital radios offer additional benefits, including the ability to compress data, enabling it to be transmitted using less bandwidth and thus reducing the chances of the network reaching the limit of its capacity.^15731573 Christopher Johnson {Day189/59:11}-{Day189/60:9}. However, congestion can affect digital radios, although in a different way. Large numbers of people communicating over a talk group can result in Airwave reaching the limit of its capacity, which, in turn, prevents a signal from being transmitted.^15741574 Christopher Johnson {Day189/93:20}-{Day189/94:12}. It follows that it is important to observe radio discipline, whichever technology is being used.

¶80.23 Most firefighters who attended the Grenfell Tower fire had only analogue radios (whether handheld or as part of a BARIE set). The LFB's handheld digital radios were reserved for officers of the rank of station manager and above.^15751575 {LFB00089144/2} paragraph 3.1.

¶80.24 The use of handheld Airwave radios was subject to stringent security requirements due to their ability to gain access to encrypted radio channels used by the police and ambulance services and for reasons of cost.^15761576 Christopher Johnson {Day189/159:11-20}; {LFB00012913/10} section 13. However, it is not clear that the security concerns surrounding the use of Airwave radios were insurmountable. The police and ambulance service use Airwave radios at all levels of seniority.^15771577 Christopher Johnson {Day189/181:5-24}.

Awareness of the limitations of radio equipment

¶80.25 Even at the time of the Lakanal House fire in July 2009, the limitations of radio equipment of the kind used by the LFB were by no means unknown, having been demonstrated at several previous large-scale incidents.^15781578 Dobson {Day212/8:24}-{Day212/9:4}. The following provide particularly clear examples. a. The King's Cross Fire, 1987. At the King's Cross fire radio communications were hindered

by underground tunnels because the thick concrete walls obstructed signals. Officers could not communicate by radio unless they could see each other. Following the fire, fixed repeaters were installed in a number of underground stations and it was recommended that the LFB deploy radio repeaters and leaky feeders. However, that had not been done by the time of the London bombings on 7 July 2005.^15791579 Johnson, Communications Expert Report {CWJ00000119/59-60}; Johnson, Communications Expert Report {CWJ00000119/183}.

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¶b. The World Trade Center incidents, 1993 and 2001. The attacks on the World Trade Center in New York are significant because they provided early warning signs that low- powered UHF radios used by emergency responders might have difficulty penetrating high-rise buildings constructed of large amounts of concrete and steel or other metal.^15801580 Johnson, Communications Expert Report {CWJ00000119/60-61}. The attacks also demonstrated that repeaters (whether fixed or portable) did not always provide an answer to that problem, particularly if they became damaged or unavailable during an incident.^15811581 Johnson, Communications Expert Report {CWJ00000119/183-185}. The 2001 World Trade Center attacks prompted DCLG to undertake research into the problems with communications that emerged during those incidents because of their importance to fire and rescue services in the United Kingdom.^15821582 Incident Communications Final Report {CWJ00000092}. Consideration was given to requiring developers or owners of large buildings to restrict the use of materials which limit the efficiency of radio equipment or to provide fixed radio infrastructure to assist fire and rescue services. Consideration was also given to reassigning UHF channels to minimise technical limitations and interference and to replacing analogue systems with digital systems. As far as we are aware, however, no action was taken in response to that exercise.

¶c. The Bethnal Green Road Fire, 2004. A failure of radio communications was identified as part of the circumstances which resulted in the deaths of two firefighters. At the subsequent inquests into those deaths, the coroner expressed surprise that it had been standard practice in the LFB for a team of two firefighters wearing breathing apparatus to be committed with only one BARIE set between them and recommended that the LFB revise its allocation of BARIE equipment. However, at the time of the Grenfell Tower fire it was still the LFB's practice to provide one BARIE set for each team of two wearing breathing apparatus, although Commissioner Dobson told us that every firefighter was issued with a fireground (UHF) radio and that an instruction has been given that all teams committed to an incident should have a BARIE set.^15831583 Johnson, Communications Expert Report {CWJ00000119/64-66}; Dobson {Day212/9:21}-{Day212/11:24}.

¶d. The London Bombings, July 2005. This incident again revealed difficulties with UHF communications underground, particularly as fixed radio repeaters had been damaged during the attacks. As a result, the Review Committee appointed by the Greater London Assembly to identify lessons to be learnt from the incident recommended that the LFB, the Metropolitan Police Service and the London Ambulance Service give it information about the provision of digital radio systems. In the meantime, it recommended an emergency underground communications system which could be put in place more quickly than a leaky feeder cable. The committee noted that no serious consideration had been given to using alternative technologies pending the provision of CONNECT (a radio communications project developed under the aegis of London Underground) and Airwave or as a backup measure in the longer term.^15841584 London Assembly's Report of the 7th July Review Committee {CWJ00000007/22} paragraph 2.30; cited in Johnson, Communications Expert Report {CWJ00000119/70-71} paragraph 4.9.12. The force of those observations was demonstrated at the Grenfell Tower fire, at which most LFB crews did not have access to an Airwave radio.^15851585 Johnson, Communications Expert Report {CWJ00000119/68-71}; Johnson, Communications Expert Report {CWJ00000119/185-187}.

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¶80.26 The evidence showed that various people within the LFB held a substantial amount of technical knowledge about how construction materials of different kinds could attenuate or block radio signals,^15861586 {LFB00001843/61} paragraph 9.3.11; Dobson {LFB00110652/3} page 3, paragraph 11; {LFB00041759}; {LFB00110654}; {LFB00001256/3} paragraph 2.9. but that those who held that knowledge did not share it widely, with the result that the organisation as a whole did not make appropriate use of it. Although national guidance could have provided a clearer explanation of why high-rise buildings cause interference with radio signals, it did draw attention to the problem and recommend that fire and rescue services have contingency plans in place to ensure the safety of firefighters. For example, GRA 3.2, issued in February 2014, pointed out that high-rise buildings may cause difficulties with radio reception, including the creation of "blind spots".^15871587 {LFB00001255/9}. The National Operational Guidance on Breathing Apparatus gave the same message when it warned that crews wearing breathing apparatus should be aware of the potential for limited penetration of radio signals through buildings and structures below ground and either make other arrangements or put contingency plans in place.^15881588 {LFB00029438/55} paragraph 6B3.24.

The Lakanal House fire

¶80.27 At the Lakanal House fire in July 2009, problems with the UHF radio signal made it difficult for the breathing apparatus entry control officer^15891589 An entry control officer manages the deployment of firefighters wearing breathing apparatus. For more information, see the Phase 1 Report Volume I, paragraphs 7.70 - 7.71. to communicate with crews relying on BARIE sets. Communications were also adversely affected by the volume of radio traffic at the incident.^15901590 Dobson {Day212/12:24}-{Day212/13:10}.

¶80.28 Despite not being a new problem,^15911591 Reason {Day182/6:21-25}. the difficulties were serious enough to prompt the LFB to investigate their cause. The LFB's Lakanal House Investigation Team, led by DAC Cutbill, was charged with that investigation. In April 2010, a radio expert, Roger Tuckley, produced a report for the LFB on the effect that steel-framed buildings can have on radio signals. It is unclear why the LFB focused attention on steel-framed buildings, since the purpose of the report was to provide answers to questions that might arise during the Lakanal House inquest.^15921592 {LFB00110657}.

¶80.29 Mr Tuckley's report, a one-page note entitled "In Building Radio User Difficulties",^15931593 {LFB00110659}. described a number of inherent restrictions affecting the use of UHF radio in the built environment, including the attenuating effect that buildings and objects within them can have on signal propagation. He also described the particular effects of certain construction materials, notably concrete, metal, solid foam insulation and insulation with foil backing. UHF radios operate best in situations where there is nothing between the transmitter and the receiver, which is typically not the case when they are used by BA crews. In view of its importance for understanding the performance of BARIE sets, the report was essential reading for the senior managers of the LFB's operational departments. Despite that, it was not brought to the attention of AC Reason when he became Director of Operations, Resilience and Training in January 2012 or when he joined the Lakanal House Board in February 2012.^15941594 Reason {Day182/3:15-23}; {Day182/4:18}-{Day182/5-22}.

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¶80.30 Despite the fact that Mr Tuckley had exposed significant limitations on the LFB's UHF radios and had provided an explanation for the poor radio communications at the Lakanal House fire, the evidence suggests that little was done in response to his report beyond including it as an appendix to the LFB's Lakanal House Operational Response Report.^15951595 {LFB00034805/59}. That report recorded only that most of the radios deployed at the Lakanal House fire had not been defective and that an unidentified report (which can only have been Mr Tuckley's report) had advised that the height and construction of the building may have contributed to some of the comments made by crews. Mr Tuckley's report did not prompt the LFB to consider how it might improve the resilience of its UHF radios or otherwise make up for their inherent limitations.

¶80.31 After the Lakanal House fire, the LFB's Incident Communications department suggested that the power of handheld radios be reviewed and that the need for intrinsically safe radios in some circumstances be re-examined, but those suggestions were not passed to AC Reason^15961596 {LFB00098635}; {LFB00098636}; Reason {Day181/208:8-11}. and neither he nor Commissioner Dobson could recall having given them any detailed consideration when preparing the LFB's response to the coroner's rule 43 recommendations. They both said that the limited power of the BARIE radios reflected national guidance, from which the LFB was unlikely to depart.^15971597 Reason {Day181/207:20}-{Day181/208:20}; {Day182/41:7-10}. However, national guidance on breathing apparatus published by DCLG in January 2014^15981598 {LFB00031268}. had recommended that the level of intrinsic safety should be appropriate to the hazards likely to be encountered and should take account of other equipment being deployed by those wearing breathing apparatus. It also stated that electrical equipment other than that which was intrinsically safe might be considered appropriate for all normal operational requirements where it would confer a significant benefit to the safety and effectiveness of teams wearing breathing apparatus.^15991599 {LFB00031268/83-84}. We are not persuaded by Commissioner Dobson's evidence that no steps were taken to implement that guidance because of disruption caused by industrial action. It was clear from his evidence that he was not familiar with it and there was no evidence within the LFB's documents that it had been considered at all, let alone of any decision to delay its implementation between January 2014 and June 2017.^16001600 Dobson {Day212/40:2}-{Day212/41:14}. In our view it is better understood as another example of the LFB's reluctance to depart from established practices.

¶80.32 Improving radio communications was not one of the LFB's pre-inquest action points (see Chapter 74). Commissioner Dobson could not account for that omission, but thought that it might have been because the problems with communications encountered at Lakanal House were not unusual and because advice had been received from technical experts that it was not possible to overcome some of them, given the circumstances in which radios were used.^16011601 Dobson {Day212/13:17}-{Day212/15:7}. However, we have seen no evidence that the LFB's senior officers were told that the problems were insurmountable, or that any consideration was given to whether they could be overcome or at least mitigated. Indeed, Commissioner Dobson's evidence was that there was no review, let alone a root and branch review, of the existing technology following the Lakanal House fire.^16021602 Dobson {Day212/47:16-21}.

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¶80.33 We find that surprising. Given the importance of the observations made by Mr Tuckley, the LFB should have taken steps to investigate the practicability of mitigating or eliminating the problems he had identified. We have been left with the strong impression that the LFB viewed the kinds of communications difficulties experienced at the Lakanal House fire as an unavoidable incident of firefighting, particularly in modern high-rise buildings. A consequence of that attitude was that nothing was done between the Lakanal House fire in July 2009 and the Grenfell Tower fire in June 2017 properly to investigate the nature, extent and causes of those well-known difficulties to see whether it might be possible to mitigate or eliminate them. No satisfactory explanation has been offered for the LFB's failure to pursue an enquiry into a matter of such importance to effective firefighting and the protection of crews.

Another review of the problem: 2013

¶80.34 In February 2013, during the course of the Lakanal House inquests, the LFB looked again at why its incident ground radios had not been wholly effective. DAC Cutbill asked GM A'Court (who was a member of the Incident Communications team) to consider the matter, but it is unclear why he did so, since, as DAC Cutbill knew, the LFB had already received detailed advice from Roger Tuckley which it had not taken seriously into account.

¶80.35 In his response dated 28 February 2013 GM A'Court explained once again that UHF radios work best in the absence of obstructions which reduce the propagation of signals and the distance over which they are effective.^16031603 {LFB00106755}. He explained that steel-framed buildings are more difficult for radio signals to penetrate than simple brick or timber-framed buildings and that the transmission strength of a signal has a bearing on its propagation. He described the signal strengths of the different channels used at incident grounds and noted that the transmission strength of BARIE radios was limited to 1 watt for safety reasons. Again, however, there was no evidence that anyone made use of that valuable description of the current equipment and the factors affecting its performance to consider the possibility of making changes to the LFB's communications policies, equipment or practices. It is surprising, to say the least, that GM A'Court's email was not brought to the attention of AC Reason, who by then was Director of Operational Resilience and Training.^16041604 Reason {Day182/15:3-14}.

¶80.36 At the conclusion of the Lakanal House inquests, the coroner recommended that the LFB consider whether it would be beneficial to use additional breathing apparatus radio communication channels and personal radio channels at major incidents to reduce the amount of traffic on each channel.^16051605 {LFB00032158/3}. In his response to the coroner of 23 May 2013 Commissioner Dobson explained that the LFB had considered doing so but had decided that using separate channels might make it difficult for crews to maintain an overview of an incident and might adversely affect operations, for example, by delaying the exchange of critical information and adversely affecting co-ordination between teams.^16061606 {LFB00042089}. The LFB concluded that the need to pass information across several channels might negate any apparent benefit because of the need to transmit the same information across all channels in use, thus reducing radio capacity and creating a risk of duplication and confusion.^16071607 {LFB00042089/8}. The Commissioner also said that the LFB had introduced breathing apparatus telemetry (a system which enables the entry control officer to monitor the air consumption of those wearing breathing apparatus),^16081608 For a more detailed explanation of this process and the equipment involved, see the Phase 1 Report Volume I, paragraphs 7.70 - 7.71. which reduced the amount of radio communication at incidents. He said that the LFB would ensure that the constraints on communication were covered in operational training, but he did not refer to the use of additional personal radio channels.

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¶80.37 Responsibility for drafting the LFB's response to the coroner's recommendations on communications rested with the Incident Communications team, which was part of the Operational Policy department.^16091609 Reason {Day181/166:7}-{Day181/167:9}. The draft identified some potential improvements to communications which went beyond the coroner's recommendation relating to the use of additional radio channels.^16101610 {LFB00034062/9}. The improvements suggested were sound and, if adopted, would have forestalled some of the concerns that have arisen during this Inquiry. They included: a. Raising crews' awareness of problems with communications at incidents and explaining how to identify and overcome them; b. Using a dedicated UHF channel for passing fire survival guidance information; c. Using additional UHF channels which had been vacated by the police; and

¶d. Using Airwave radios to provide additional incident command channels if communication difficulties occurred at larger incidents.

¶80.38 For the sake of completeness, we note that an earlier draft of the document,^16111611 {LFB00098636}. which GM A'Court sent only to AC Knighton (then the Head of Operational Procedures)^16121612 {LFB00098635}; Reason {Day181/208:8-11}. also suggested the following: a. Carrying out a detailed risk assessment of the need to use intrinsically safe radios and equipment;

¶b. Including the effectiveness of UHF radios in the information to be gathered during section 7(2)(d) visits; and c. Training command unit staff to provide communications advice to incident commanders.

¶80.39 The Commissioner's Group rejected the suggestions. Neither Commissioner Dobson nor AC Reason could remember why they had done so, beyond referring to a general (but not obviously well-founded) belief that the LFB's systems were adequate.

¶80.40 Following the Grenfell Tower fire, the Operational Policy and Assurance department reviewed the specifications for fireground and breathing apparatus radios in advance of procuring new equipment. The review recommended that a single specification providing a transmitting power of 4 watts should be adopted for all UHF radios, but that a stock of radios with a higher intrinsic safety rating should be retained for specialist operational use.^16131613 {LFB00105466/1}. That approach could have been taken earlier in response to the national operational guidance on breathing apparatus issued by the DCLG in January 2014.

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Communications training: the failure to implement TCAP 0039

¶80.41 The LFB's response to the coroner's rule 43 letter was that it would ensure that the constraints on communications at incidents were covered in current operational training. In May 2013, however, the LFB provided very little training on the use of radio equipment beyond the initial training given to recruits as part of their firefighter development programme.^16141614 Groves {Day177/191:22}-{Day177/198:1}. The estimated completion date for the enhanced incident communications training was December 2013.

¶80.42 AC Reason said that he had understood that the new training would cover subjects such as using the correct equipment, using the correct channel, the availability of alternative channels, highlighting potential interference with the propagation of radio signals, the effect that certain kinds of buildings can have on the propagation of signals, options for circumventing problems and the equipment available for that purpose.^16151615 Reason {Day182/43:1-15}; {Day182/44:3-9}. The view within the LFB was that its communications procedures had broken down at Lakanal House because of the immense pressure under which firefighters were operating and that training might help to ensure that the procedures required to communicate more effectively were fixed in the minds of firefighters.^16161616 Dobson {Day212/20:19}-{Day212/21:8}.

¶80.43 The process for commissioning that training was initiated by TCAP No. 0039,^16171617 {LFB00004729}. which was first issued on 27 July 2012, a date which indicates that the need for such training had been identified even before the Lakanal House inquests had begun. The training requirement was described in the form as being to ensure that all operational personnel had the knowledge and understanding required to use radio communication equipment in accordance with LFB policy to ensure effective communication at incidents.^16181618 {LFB00004729/7}. The final version, dated 10 March 2015, did not refer to the problems with communications experienced at Lakanal House or to the coroner's recommendation. AC Reason said that he would have expected it to have done so, but plainly it did not.^16191619 Reason {Day182/58:8-15}. The absence of any reference to the LFB's experience at the Lakanal House fire or to the coroner's recommendation meant that the substance of the training programme was not informed by the matters it was intended to address. Once more, no senior LFB officer was able to explain that omission and there is no contemporaneous, or indeed any, document that explains it.

¶80.44 The resulting training packages were examined in detail during the oral evidence. Although the training package for station-based staff (that is, firefighters up to and including the rank of watch manager) described LFB radio equipment and radio enhancing equipment, it failed to explain how to use it or how to overcome communication failures. It did not explain the effect that the built environment can have on the propagation of radio signals, although that had emerged clearly from the Lakanal House fire and the LFB's own investigations.^16201620 Reason {Day182/60:9}-{Day182/63:17}; Groves {Day178/3:2-13}; {Day178/4:13-17}. Although the package for senior officers (station managers and above) provided more detailed information about the LFB's radio equipment, it too failed to provide advice on how to overcome communications difficulties or information about the effect of the built environment on radio signals.^16211621 Reason {Day182/63:18}-{Day182/67:13}. Neither training package suggested the use of Airwave radios as a way of overcoming communication difficulties,^16221622 Reason {Day182/83:5-21}; {Day182/88:9-11}; {Day182/92:15}-{Day182/93:7}. nor did either of them distinguish between radio repeaters and telemetry repeaters, which became a source of confusion on the night of the Grenfell Tower fire.^16231623 Reason {Day182/67:14}-{Day182/68:3}. In short, the substance of the training packages did not adequately address the problems that had been clearly identified by both the LFB itself and the Lakanal House coroner. We have seen no evidence to suggest that anyone reviewed the content of the packages to see whether they covered those matters adequately.

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¶80.45 However, the shortcomings of both training packages are completely overshadowed by the LFB's failure to deliver them. Although they were approved, after some delay, in May 2015, they were not delivered to staff. The LFB attributed that failure to problems with its computer training system, which at many stations could not support training packages containing videos.^16241624 Groves {Day177/174:15}-{Day177/176:7}. However, only the package designed for senior officers contained video; the package designed for station-based crews was not affected by the limitations of the system. Peter Groves, the former Head of Development and Training, explained that a number of attempts had been made to solve the problem, none of which had been successful, and accepted that the videos could easily have been provided to stations by other means, such as CDs. That solution was apparently not considered, although it had been adopted for other training packages.^16251625 Groves {Day177/179:2}-{Day177/181:3}; {Day177/197:7}-{Day177/198:1}.

Management failures

¶80.46 The story of communications is one of a succession of senior management failures to take active steps to improve what was known to be an unsatisfactory position. The rejection of GM A'Court's proposals and the absence of any record of the reasons for rejecting them illustrate the LFB's defeatist attitude towards the difficult task of providing effective communications. Our overriding impression is that the LFB's senior officers saw the difficulties with communications as an intractable problem not amenable to any solution and for that reason nothing was ever done about them. However, given the obvious importance to firefighting operations of effective communications, such an attitude also suggests an unjustified complacency about the LFB's ability to fulfil its role effectively without reliable communications.

¶80.47 The decision of the Commissioner's Group not to adopt GM A'Court's proposals is even more striking in the light of the publicity then being given to the problems with communications that had been encountered by the Hampshire Fire and Rescue Service during the Shirley Towers fire and were being investigated by the Hampshire coroner. The Hampshire Fire and Rescue Service's report into that fire had been published on 8 April 2013, a few weeks before the Commissioner's Group met in May 2013. It recorded that the handheld radios used by Hampshire Fire and Rescue Service did not always operate effectively in high-rise buildings and that the problem of poor radio communications in high-rise buildings was well known.^16261626 {LFB00107130/53}.

¶80.48 The report of the investigation into the Shirley Towers fire was released a week after the coroner at the Lakanal House inquests had made her rule 43 recommendations. AC Reason said that he had read the report when it was released and that it had been the subject of a report to the co-ordination board.^16271627 Reason {Day182/16:24}-{Day182/17:8}; {Day182/18:10}-{Day182/19:8}. In his evidence he agreed with the report's conclusion that it had been well known that radio communications within high-rise structures could present problems, a matter of which the LFB had already been aware,^16281628 Reason {Day182/19:10-18}. but he had no clear recollection of the extent to which, if at all, the report had affected the LFB's response to the coroner's rule 43 recommendations.^16291629 Reason {Day182/19:19}-{Day182/22:2}. The LFB did produce a draft plan, dated 8 October 2012, for responding to various aspects of the operations at Shirley Towers, which included reviewing the meaning of a prolonged breakdown in radio communications referred to in materials such as procedures and training materials. The task was given to Operational Procedures,^16301630 {LFB00100307} item 23. but we saw no evidence that any review had been carried out. AC Reason did not know whether any action had been taken in response.^16311631 Reason {Day182/100:9-25}.

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¶80.49 The problems identified by the investigation into the Shirley Towers fire echoed problems which were well known to the LFB and the reaction of its senior officers reflected their defeatist response to the problems experienced during the Lakanal House fire. Although the causes of those problems had been identified by some within the organisation, the LFB failed to consider how best to address them. In essence, the Shirley Towers report did not prompt the LFB to reconsider its communications practices or policies, or, importantly, its response to the Lakanal House coroner's recommendations on radio communications. As the Shirley Towers fire was yet another high-rise incident at which difficulties had been encountered using UHF radios, it should have elicited a more energetic response. Senior officers were unable to provide a satisfactory explanation for why nothing had been done.

¶80.50 In 2014, the LFB's Operations, Resilience and Training Directorate had intended to replace the existing BARIE sets with more modern equipment, but the purchase of the new equipment was deferred because the current equipment was still available and was thought to operate effectively.^16321632 {LFB00088188} first row. That decision was unfortunate, given the wealth of evidence that many firefighters regarded the existing BARIE sets as unsatisfactory due to their limited range and the difficulties encountered in using them.

¶80.51 Apart from the BARIE sets, whose transmission power was limited to 1 watt, handheld radios could transmit at up to 4 watts. However, although channel 1 (the default incident command channel) operated at the full 4 watts, for historical reasons related to the previous generation of equipment, radios were set to transmit on other channels at 2.3 watts.^16331633 {LFB00106755}. Although that must have been known to some people in the LFB, by June 2017 no steps had been taken to increase the transmission power of handheld radios to 4 watts on all channels following the introduction of the current equipment in about 2007.^16341634 In his statement to the MPS, Dominic Ellis explained that the LFB's working assumption was that the wattage of the other channels was based on previous radios held by the LFB, known as the Maxon radio. Director Reason's evidence was that the Maxon radios were replaced by the HX series in 2007/2008, following the Bethnal Green fire in 2004: Reason {Day182/57:1-6}. There is no evidence, whether in this statement or elsewhere, that the issue of restricted wattage had been rectified by 14 June 2017: Ellis {MET00077839/9} page 9.Show full note

¶80.52 The story of TCAP No. 0039 is one of incompetence and inefficiency. The aim of the training packages was to address the kind of problems with communications that had been experienced at the Lakanal House fire, but their contents owed little to the LFB's consideration of those problems or to the coroner's recommendation and did not deal with them adequately. The LFB had access to three 'spare' UHF channels (channels 4, 7 and 8), but in June 2017 it was not its policy or practice to use them.^16351635 Johnson, Communications Expert Report {CWJ00000119/48} paragraphs 3.5.8 and 3.5.9. The Incident Communications department drew attention to the possibility of using those additional channels,^16361636 {LFB00034062/10}. but senior officers decided against doing so, on the grounds that the benefits were likely to be outweighed by a lack of oversight of communications, a lack of co-ordination, and the possibility of delay in sending critical information.^16371637 {LFB00042089/8}. However, that reasoning is not consistent with the policy that firefighters wearing breathing apparatus should transfer from channel 6 to channel 5 if radio repeaters or leaky feeders have been deployed.^16381638 Christopher Johnson {Day189/88:20}-{Day189/89:22}.

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¶80.53 AC Reason told us that interference between channels had been a factor in the decision not to bring one of the available spare channels (channel 4) into regular use.^16391639 Reason {Day181/179:18}-{Day181/180:7}. Although that may be the case, we agree with Professor Johnson's view that it might have been possible to persuade the government to reallocate the channels to maximise the use of the available frequencies.^16401640 Christopher Johnson {Day189/80:13}-{Day189/81:4}. The fact that the LFB has brought some of those channels into regular use following the Grenfell Tower fire suggests that the problems of interference were not insurmountable.

¶80.54 An increased number of radio channels adds complexity to an incident and requires a robust system to ensure that the incident commander is made aware of all important communications. However, that should not represent an unduly onerous burden for a fire and rescue service responding to a large incident. A system of that kind is required at any incident where more than one radio channel is used, because an incident commander cannot be aware of all the communications generated, as LFB policy recognises.^16411641 Johnson, Communications Expert Report {CWJ00000119/50} paragraphs 3.5.10 - 3.5.15. That complexity, and the potential need for a communications officer to oversee communications at larger incidents, will often be justified by the resilience that additional radio channels bring to fireground communications.

¶80.55 The LFB knew that the transmitting power of a radio and the surroundings in which it is being used both have a direct effect on the range of the signal. It should, therefore, have increased the transmitting power of handheld UHF radios and considered providing more powerful BARIE sets for use at residential fires, particularly those in high-rise buildings. A good start would have been to make a detailed assessment of the level of risk that wearers of breathing apparatus are exposed to using equipment with different levels of power, how frequently such risks arise, the effect of using more or less powerful radios and how the quality of communications could be improved in situations in which it was considered necessary for BARIE sets to remain intrinsically safe. AC Reason said that no such assessment had been carried out during his time.^16421642 Reason {Day182/40:22-25}-{Day182/41:1-10}; Christopher Johnson {Day189/32:12}-{Day189/33:21}.

¶80.56 The abundance of concrete, steel and more modern construction materials in Grenfell Tower is likely to have contributed to the significant deterioration of radio communications experienced by firefighters and officers in and around the tower on 14 June 2017. After the fire, the LFB tested radios at Grenfell Tower and found that they performed better than on the night of the fire. As a result, it attributed the problems it had experienced to congestion.^16431643 Johnson, Communications Expert Report {CWJ00000119/159} paragraph 6.14.1. We agree with Professor Johnson that that is an oversimplification.^16441644 Christopher Johnson {Day189/108:5-9}; {Day189/115:1}-{Day189/122:3}. Although congestion is likely to have played a part in the failure of effective communications, we think it likely that the significant changes to the structure of the building brought about by the fire itself (including the destruction of most of the facade) explain most of the difference between the test results and the conditions experienced by firefighters on 14 June 2017.^16451645 This was acknowledged by the LFB in its testing methodology {LFB00084087/3}. We also accept Professor Johnson's opinion that signal propagation can be influenced by factors such as the weather and the presence of fire itself,^16461646 Johnson, Communications Expert Report {CWJ00000119/43} paragraphs 3.2.15 – 3.2.18; Christopher Johnson {Day189/15:11-18}. and that those factors must also be borne in mind when considering the results of the LFB's tests.

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Conclusions

¶80.57 Notwithstanding its experience at the Lakanal House fire, the LFB did not teach firefighters or officers that the structure of a building and the materials from which it is made can interfere with radio signals, beyond giving them a broad indication that there can be blind spots within high-rise (or indeed other) buildings.^16471647 Groves {Day177/192:6}-{Day177/194:4}; Reason {Day182/60:9}-{Day182/63:17}; {Day182/63:18}-{Day182/67:14}. More significantly, the LFB did not provide sufficient guidance to firefighters and incident commanders on how best to overcome difficulties with communications encountered in high-rise buildings. Such training may also have helped crews identify the risk of poor radio communications during section 7(2)(d) visits.

¶80.58 The LFB's communications at the Grenfell Tower fire were generally ineffective.^16481648 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.130. That was the result of many different failings and shortcomings, but in summary, the equipment deployed by the LFB on 14 June 2017 was inadequate, firefighters were not trained to identify and mitigate well-known and frequently encountered problems and LFB policies did not contemplate a widespread loss of communications or provide guidance on how they could be effectively restored.^16491649 Although Commissioner Dobson thought that wholesale loss of communications was covered in training Dobson {Day212/49:18}-{Day212/50:6}, it was clear from Mr Groves' evidence that that was not the case: Groves {Day177/192:6}-{Day177/194:4}.

¶80.59 Occasional failures of equipment are only to be expected and major incidents will always suffer from obstacles to consistently effective communications. However, that makes it all the more important to have contingency arrangements in place that can function cohesively to ensure the effective transmission of information. The LFB's communication system on the night of the Grenfell Tower fire fell well short of achieving that objective.^16501650 Christopher Johnson {Day189/198:3}-{Day189/199:6}.

¶80.60 In our view, the LFB's approach to communications was to do the best it could with what it had available. As a result, it failed to make sufficient efforts to modernise its equipment and eliminate well-recognised defects in its systems.^16511651 Christopher Johnson {Day189/202:2}-{Day189/208:1}. The LFB's senior management concentrated almost exclusively on congestion as the primary cause of problems at large incidents, but for reasons given earlier, although a contributory factor, that was not the real difficulty. Senior managers appear to have accepted that communication problems were only to be expected and since little was done to challenge that conclusion and the suggestions made by the incident communications team were not implemented, no improvements were made. As a result, the LFB's operational efficiency was significantly impaired.

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¶80.61 The history of this matter neatly encapsulates the chronic defects in the LFB's approach to well-known problems with incident ground communications. It consistently failed to accord to radio communications the significance and attention that they deserved, to address the problems that had been clearly identified and to train its personnel on how to deal with them when they arose. None of the senior officers who gave evidence was able to explain satisfactorily why the LFB had persistently failed to make a serious effort to solve problems which, although undoubtedly complex, were critically important for effective firefighting operations. For example, it is possible to set up a number of temporary Airwave talk groups for specific incidents or aspects of incidents, which is how the police and ambulance service use the system.^16521652 Christopher Johnson {Day189/95:2}-{Day189/96:2}. There was no evidence to suggest that the LFB had considered using talk groups in that way, other than for training exercises, which may be a reflection of the limited number of officers who had personal Airwave radios. The broader adoption of digital radios (whether Airwave or otherwise), combined with the effective use of talk groups or channels, should have received more active consideration by the LFB before the Grenfell Tower fire. That might have improved the poor quality of communications inside the tower on 14 June 2017.

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