Chapter 83: Conclusions

Chapter 83: Conclusions

¶83.1 In the Phase 1 report the chairman recognised that the firefighters who attended the Grenfell Tower fire displayed enormous courage and selfless devotion to duty.^17711771 Phase 1 Report Volume IV paragraph 28.1. We echo that finding, but their bravery and commitment to duty is only a part (albeit a significant part) of the picture. Another part is the inescapable fact that the systemic failings of the LFB on the night of the Grenfell Tower fire relating to training, incident command, communications and the operation of the control room had all been foreshadowed by previous fires, most particularly, the Lakanal House fire on 3 July 2009.

¶83.2 The LFB did not fail to identify or understand the lessons to be learnt from the Lakanal House fire and other major fires involving high-rise buildings constructed using modern materials and methods of construction. On the contrary, its response to the Lakanal House fire in particular showed that it understood its significance immediately. The LFB quickly analysed the incident and identified the appropriate lessons including the broader implications of the increasing use of modern materials and their role in promoting external fire spread. In that regard, Commissioner Dobson's correspondence with DCLG in December 2012 showed commendable foresight in anticipating many of the questions that have been investigated in Phase 2.

¶83.3 The LFB's failure lay in its inability to implement any effective response. That failure had many causes, but it is possible to identify in the evidence summarised in previous chapters a number of distinct but closely related aspects of the way in which the LFB was managed which, in our view, account for it. The evidence clearly shows that the LFB's failure was attributable to a chronic lack of effective leadership, combined with an undue emphasis on process and a culture of complacency. Senior officers appear to have thought that establishing bodies to review and report would inevitably lead to action without the need for effective monitoring of progress and further action being taken as necessary to ensure completion. Complacency led to a failure to ensure that knowledge of the dangers presented by the increasing use of combustible materials were reflected in operational policies and procedures.

¶83.4 Ron Dobson and Dany Cotton, as former Commissioners, bear ultimate responsibility for the LFB's inability to take effective action after the Lakanal House fire. It is to their credit that neither of them shirked nor sought to qualify that responsibility. However, their acknowledgment should not obscure the failures of other senior officers who were directly responsible for the efficiency and effectiveness of their departments. In the decade before the Grenfell Tower fire, Dave Brown, as Third Officer and Director of Operations, oversaw a broad range of the LFB's activities which have featured heavily in Phase 2.

¶83.5 Two failings, in particular, illustrate AC Brown's approach to command and management and explain in part why recommendations were not carried out effectively. The first concerns the inspection of high-risk high-rise residential buildings. That function was (and remains) a necessary and important means of making sure that the LFB discharges its duties under the 2004 Act and the Health and Safety at Work Act 1974. AC Brown did not wish to become involved in considering the complexities of an inspection regime, a problem which deserved more careful consideration than he was willing or able to give it. If the letter and spirit of the Lakanal House coroner's recommendation were to be met and more effective inspection arrangements introduced, GM Elwell's recommendations required proper consideration. AC Brown failed to give them that consideration and, as far as we can see, there was no good reason for that. If those proposals had been implemented, they could have gone some way towards remedying the deficiencies in the LFB's arrangements for gathering and managing operational risk information.

¶83.6 The second example relates to the control room. The importance of fire survival guidance refresher training for CROs is obvious. The senior officers responsible for the control room (including AC Brown and POM Hayward) plainly understood that importance, particularly because of the weaknesses in handling calls exposed by the Lakanal House fire. In 2009, no structured or regular fire survival guidance refresher training was provided by the LFB and this was still the case at the time of the Grenfell Tower fire in 2017. The failure to give CROs regular fire survival guidance refresher training is a serious shortcoming, particularly by those officers who were responsible for making sure that effective training was provided. Even allowing for the difficulties flowing from the introduction of Vision, there is no justification for such a longstanding failure to address a vital element of the control room's work and one which touched directly upon public safety.

¶83.7 An aggravating feature is that even though the Lakanal House fire demonstrated the real danger to life posed by the failure to provide effective fire survival guidance training, none of senior officers responsible for the operation of the control room ever tackled the challenge of providing the necessary training with the dedication it deserved.

¶83.8 Although individuals undoubtedly had a role in the failings which have been examined here, it is important to stress that they were committed in the context of broader structural and cultural problems. It is clear that the LFB's response to the Lakanal House fire placed undue reliance on process. Boards were established, plans were made and reviews were commissioned, but no effective steps were taken to ensure that recommendations had been effectively implemented, particularly in relation to the danger of relying uncritically on compartmentation, the risk of fire spreading across external walls and the ability to handle many fire survival guidance calls simultaneously. Because those matters were not addressed in the resulting training packages, the recommendations were not fully implemented and so the defects that had been identified were not remedied.

¶83.9 The root cause of the problem was that the LFB's senior officers lacked the necessary degree of managerial competence to recognise and correct problems. One stark illustration of that shortcoming is the failure to translate its longstanding knowledge of the dangers posed by modern materials and methods of construction into operational policies that recognised and reflected those dangers. Another is the failure to ensure effective management of the control room, particularly in relation to training. Commissioner Dobson was alert to the danger posed by the use of combustible materials and in December 2012 recommended certain measures to DCLG that might have alleviated it. However, in the eight years between the Lakanal House fire and the Grenfell Tower fire neither he nor his successor took any steps to review and revise the LFB's operational policies, procedures and training to make sure that firefighters (and incident commanders in particular) understood how best to respond to a fire that had taken hold in the external wall of a high-rise building. Nor did they take any effective steps to ensure that control room staff received essential training.

¶83.10 The managerial weaknesses we have identified resulted in part from the historic separation between the departments responsible for operational matters and those responsible for support functions and a lack of effective communication between them. Historically, the Fire Safety department, like the control room, had become isolated from the operational departments, leading to a failure to communicate information about the dangers of combustible materials and a corresponding failure to ensure that they were taken into account in the policies and training. For a long time that failure was compounded by an entrenched but unfounded assumption that the regulatory regime in the Building Regulations was sufficient to prevent such dangers from arising in this country. After the Lakanal House fire senior officers recognised that compliance with the regulations could not be guaranteed, but no one appears to have thought that firefighters needed to be trained to recognise and deal with the consequences. That was partly because senior officers were confident that existing training and operational practices were comprehensive and that the additional measures identified following the Lakanal House fire had been implemented. The Grenfell Tower fire showed, however, the extent to which that confidence was misplaced.

¶83.11 Confidence in existing practices and procedures manifested itself in other ways. When a problem arose which called for careful and detailed consideration, on too many occasions the LFB's response was that change was unnecessary or too difficult, even in matters which touched upon operational or public safety. The problems with radio communications in high-rise concrete buildings provide one example. Although they were well known and regularly encountered, no effective steps were taken to investigate them to identify reliable and effective solutions. The problems were simply considered too intractable. That attitude to perennial communications difficulties was unsustainable, primarily because they were a recurring feature of inquests into the deaths of both firefighters (as at the Shirley Towers fire) and members of the public (pre-eminently, at the Lakanal House fire). Given the evident danger to the life and safety of its personnel and the public, there were compelling reasons for the LFB to invest considerable effort in seeking to resolve the problems that had afflicted radio communications for so long, but regrettably nothing effective was done.

¶83.12 There is one further point that we need to address in this context. Although we acknowledge the strength of opinion held by some that the approach to funding public services adopted by the government between 2010 and 2015 and by the Mayor of London between 2012 and 2016 constrained the LFB's operational effectiveness, none of the witnesses from whom we heard told us that insufficient financial or other resources had caused or contributed to the failings that occurred on the night of the Grenfell Tower fire. In that respect, it is telling that the LFB did not suggest that budgetary constraints had been responsible for any of its shortcomings and it is worth noting that the report of Her Majesty's Inspectorate of Constabulary and Fire and Rescue Services on the LFB, published after the Phase 1 report on 17 December 2019, stated that, although the brigade was inefficient in its spending, it was not under-funded.^17721772 "Effectiveness, efficiency and people 2018/19 – London Fire Brigade" pages 30-33.

¶83.13 The tragic conclusion is that the Lakanal House fire in July 2009 forewarned the LFB about the existence of the shortcomings which revealed themselves once more on the night of 14 June 2017. Those shortcomings could have been avoided if the LFB had been more effectively led in a number of respects, particularly in its response to the Lakanal House fire, and if use had been made of its knowledge of the dangers flowing from modern materials and methods of construction. On any view, that is a serious indictment of an organisation whose principal purpose is to protect the public and of the quality of its leadership.