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Grenfell Tower Inquiry diary week 50: ‘There is a culture in LFB that is very conservative. I think there is great comfort in what is familiar’

Insight08.10.213.30 PM by Peter Apps

This week the inquiry heard how the London Fire Brigade (LFB) elected not to issue warnings about dangerous cladding before Grenfell and a detailed examination of its policy for checking high-risk buildings. Peter Apps reports

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This week the inquiry heard how the London Fire Brigade elected not to issue warnings about dangerous cladding before Grenfell and a detailed examination of its policy for checking high-risk buildings. Peter Apps reports #UKhousing

The examination of three witnesses at the Grenfell Tower Inquiry this week focused on similar issues to the past two: an apparent failure to learn the lessons from previous fires, most notably the Lakanal House blaze that killed six in south London in 2009, and a general resistance to change ahead of Grenfell.

These are the key issues that were discussed.

‘This could be the proverbial ‘cat out of the bag’ on this issue’

Dan Daly gives evidence to the inquiry (picture: Grenfell Tower Inquiry)

This week began with assistant commissioner Dan Daly being grilled about the LFB’s response to a fire at Shepherd’s Court in August 2016, which spread over five floors after it lit combustible panels installed beneath windows.

The inquiry heard this week that the brigade obtained testing in October 2016 which showed that panels had ‘delaminated’ in the fire, exposing timber and polystyrene, which had fuelled the blaze.

An internal LFB email from the same month said this was “further evidence” about poor standards in the construction industry and a lack of understanding about regulations. More evidence about this issue should be gathered as a result, it said, with a consideration of prosecution and enforcement for rule-breakers.

Another officer replied: “Please bear in mind that every time we does [sic] this [enforcement], there is a partnership at stake and a very key one… in this case.”

This was a reference to the local authority, Hammersmith and Fulham, which – the email noted – had treated the fire as “a good news story” because it did not spread internally.

“Is it fair to say that your approach at this point was a cautious one, given the relationship that you wanted to preserve with London local authorities?” asked counsel to the inquiry Richard Millett QC.

Mr Daly did take action in relation to Hammersmith and Fulham, but added: “I was certainly urging caution elsewhere until we had the evidence.”

A meeting was then arranged between several key personnel for December 2016 to discuss the next steps. The meeting invite noted that the LFB was preparing a response that would “include recommendation on investigation /assessment/remedial works regarding the external cladding and its performance in fire”.

“Any direction we provide to H&F will be equally applicable to most other local authorities and private blocks and could involve significant expenditure,” it said. “This could be the proverbial ‘cat out of the bag’ on this issue and AC Daly has asked that we consider what the advice should be, the implications of the advice, if we enforce or advise, and how we get the message out, amongst other things.”

“What did you mean by cat out of the bag?” asked Mr Millett.

“I think London Fire Brigade are largely a respected organisation, and if there was unfounded concerns raised without the evidence to support it, that could cause distress for residents living in these types of buildings, it could trigger a disproportionate response from building owners,” Mr Daly said.

He said he was “more concerned that there would be an uncontrolled and untargeted response, as opposed to withholding information”.

In the event, the meeting agreed to seek legal advice before taking any steps. Ultimately, a warning was issued to all London boroughs in April 2017 that focused on the specific issue of flammable panels beneath windows and advised them to consider it in their risk assessments.

This letter was in fact sent around the same time as the brigade released the testing report to Inside Housing, which had submitted a Freedom of Information request demanding it weeks earlier.

“Would it be right to characterise the warning in this letter as narrow, focused and incremental, and based entirely and solely on what you could empirically observe from the Shepherd’s Court fire?” asked Mr Millett.

“Yes, I think our experience of trying to raise the issues more broadly in the past had met with little success. What I think I was hoping to achieve here was to get a focused and targeted awareness of what was going on in the London building stock, which then in turn may well provide us with evidence to take issues further,” said Mr Daly.

Nonetheless, why was a clear warning not at least issued to LFB’s own frontline to be aware of the risk of rapid fire spread?

Mr Daly’s answer was that the operation at the tower had been a success. “I think the previous learning had obviously been successful in the operations that were applied at Shepherd’s Court,” he said.

Just weeks later Michael Dowden, the watch manager at North Kensington fire station at the time of the Grenfell Tower fire, would witness flames starting to lick up Grenfell Tower and elect not to order an evacuation of the building. He would go on to tell the inquiry he had “never seen a fire behave in this way. It was totally unprecedented.”

‘There is a culture in London [Fire Brigade] that is very conservative and I think there is great comfort in what is familiar’

Dr Sabrina Cohen Hatton gives evidence (picture: Grenfell Tower Inquiry)

On Tuesday, the inquiry heard from Dr Sabrina Cohen-Hatton, a senior firefighter who also holds a PhD in psychology and has researched and written widely about the decision-making of incident commanders during fires.

This research had helped to underpin new national guidance to fire authorities, issued in 2013, which advised changing the ‘decision-making model’ for incident commanders to a new system that took more account of the “human factor” – ie the way people actually think and reason during a high-pressure event.

Dr Cohen-Hatton also held a senior role at the LFB in 2015 when it considered this guidance and ultimately elected not to adopt it.

We saw a report from July 2015 that branded the new guidance simply “a useful tool for selection and development” but that said it “should not lead to wholesale changes in the [decision-making model] or other policies”.

Dr Cohen-Hatton sought a meeting with then-assistant commissioner Dany Cotton, who would go on to lead the brigade at the time of the Grenfell Tower fire, to try to persuade her to adopt the guidance.

“Ultimately, I was told that the London Fire Brigade didn’t intend to depart from the use of the [existing decision-management model],” Dr Cohen-Hatton told the inquiry, something she said left her “surprised and disappointed”.

She said that Ms Cotton had cited the fact that it was difficult to understand for people with dyslexia – but that this was based on showing it to one colleague with the condition, who found it confusing.

In fact, Dr Cohen-Hatton said research suggested that “having some kind of scaffolding to support a decision-making process would actually be beneficial, as opposed to inhibitory” to people with dyslexia.

“There is a culture in London [Fire Brigade] that is very conservative,” she said. “And I think there is great comfort in what is familiar, because it’s seen as tried and tested. [But] if you always do what you’ve always done, you’ll always get what you’ve always got.”

Mr Millett asked: “Was there anything special about London that would justify this kind of exceptionalism when it came to the decision-making model?”

“No, not that I could reasonably propose,” replied Dr Cohen-Hatton.

‘Would it have been a source of concern to you… that more than 5,000 high-rise properties were not on the [database]?’

David Brown gives evidence to the inquiry (picture: Grenfell Tower Inquiry)

Fire authorities are required to visit certain premises to obtain information that may be useful if they are ever required to fight a fire there.

These visits – known as Section 7(2)(d) visits after the legislative passage that requires them – are a key focus of this phase of the inquiry.

That’s because the information recorded for Grenfell on the LFB’s ‘Operational Risk Database’ was found to be “woefully inadequate” in the inquiry’s first phase.

It included no plans of the building, no photos beyond a small aerial shot, the wrong number of floors, and a box titled ‘tactical plan’ left empty and dated October 2009.

After hearing from the firefighters in North Kensington who inspected the tower before the blaze, the inquiry’s first phase report concluded that the failings which led to this were “institutional in nature”.

On Wednesday, the inquiry heard from David Brown, a former assistant commissioner who was made responsible for making changes to these visits after the Lakanal House coroner specifically identified them as an area for reform.

This involved the creation of a new policy – Policy 800 – which set out how risk was to be analysed, buildings prioritised and the information collected and disseminated.

This policy provided a grading score that determined the frequency with which the brigade would make repeat visits. Any building that scored above 150 was supposed to be included in this system.

Mr Brown said this would result in “the absolute vast majority” of high-rise buildings going onto the database.

But data from October 2017 (six months after Mr Brown retired) said that only 1,700 of 6,900 high-rise buildings in London were included.

“Would it have been a source of concern to you… that more than 5,000 high-rise properties were not on the [database] and were therefore not subject to scheduled visits?” asked counsel to the inquiry Andrew Kinnier QC.

“Absolutely, and it was a concern of mine when I was in post, and it was one of my many things that we were trying to improve,” said Mr Brown. He explained that the brigade “could never get a complete straight answer” about how many high rises there actually were in London and said it “did an awful lot of work” trying to determine that.

What is mysterious is that in April 2009, he sent an email to all London stations telling crews to “diarise, book and visit the high-rise premises on their station’s ground” and carry out repeat inspections “annually thereafter”.

“That was back in 2009,” he said when asked to account for the email. “I think once the enormity of the task become more apparent, then we took more of a risk-based approach.”

An email sent by a colleague three years later discussing this point said: “This was the ‘knee jerk’ list where the message said visit every high rise… but what Dave meant was add one of the blocks in an estate if there are unusual or very difficult circumstances to be found there… he couldn’t say this in an email of course and we… therefore had to make sure people understood it.”

Asked where the author of this email could have got this impression from, Mr Brown said: “I don’t know. I think that’s something that only [he] would know himself.”

Policy was changed in 2015 to remove the requirement to visit all high rises. Mr Brown said he “could not recall” being consulted on this change.

‘I don’t think I’ve ever seen this before and Dave Brown would definitely not have allowed us to do this’

Dany Cotton appeared before the inquiry in its first phase (picture: Grenfell Tower Inquiry)

In February 2013, an LFB corporate management report said that its processes for gathering information through these visits “appear to be robust and largely in compliance” with national guidelines.

But it did also recommend that an audit take place of the consistency with which stations identified buildings.

This audit, however, appears never to have taken place. In an email sent almost five years later in December 2017, a senior firefighter asked then-commissioner Ms Cotton (pictured above during the inquiry’s first phase) if it ever happened.

“No, I don’t think I’ve ever seen this before and Dave Brown would definitely not have allowed us to do this!!” she responded.

Mr Brown insisted that while an official audit may not have taken place, the database was regularly audited by his team as part of “normal business”.

He described Ms Cotton’s comments as “really disappointing” and said he had “no idea why [she] would suggest such a thing”.

Following the coroner’s investigation into the Lakanal House fire in 2013, the brigade also promised to take several actions in response to her call for improvements in relation to the visits. This included a review of existing policy, the creation of an inspection regime for “high-priority buildings” and setting corporate targets. Mr Brown led this process.

With regard to setting the inspection regime, Mr Brown asked for the assistance of another firefighter, who in turn passed it down to John Elwell – the borough commander for Kingston – to draft a proposal. Mr Elwell produced his paper in December 2013.

Among several other things, he specifically raised the issue of “sub-standard entries” in the database.

“This could indicate a poor understanding of the rationale and a lack of competency,” he wrote, recommending “further training is provided to all personnel with a role in the [database process]”.

Asked if this was a “concern”, Mr Brown replied “absolutely” and said it was something he had “reflected on”.

“Did you reflect upon it to the extent of actually taking action, for example requiring further training to remedy the potential problems identified by Mr Elwell, poor understanding of the rationale and a lack of competency?” asked Andrew Kinnier, counsel to the inquiry.

Mr Brown said the call for more training was a “valid point”, but added: “My position on that was we had only just rolled out the training some six or seven months prior to that.”

This training had in fact been rolled out in March 2013. Mr Kinnier showed Mr Brown slides, noting that “the training nowhere provides any guidance on how crews should actually go about identifying risks when carrying out the visit”.

Mr Brown defended this training package, saying that it “remedied any previous defects” and insisting that it “gives the opportunity for crews to practice that linear premises risk assessment”.

‘How are we supposed to determine whether one piece of cladding is any different to another?’

In the first phase of the inquiry, firefighters were asked why they did not ask for details about the cladding system when they visited Grenfell. This week, we looked at the policy that sat behind that.

The local LFB policy required firefighters to include “any building construction features which may promote rapid or abnormal fire spread” and specifically referenced sandwich panels.

This was based on national guidance to fire authorities, which included a list of such potential features. This national guidance specifically included the phrase “cladding systems”, which was omitted from the LFB’s list. Why?

“I think that’s probably a question that’s better aimed at those who wrote the policy notes,” said Mr Brown. “I think we did have this issue in the brigade about not overloading staff with information and just point them in the direction of things to consider.”

What about after Lakanal and Shepherd’s Court? Didn’t these fires prompt the brigade to specifically instruct crews to consider cladding when making visits?

“Even if we had done that, then there would have been questions in terms of: well, exactly what are we looking for?” said Mr Brown. “How are we supposed to determine whether one piece of cladding is any different to another? How do we know if there are voids? What do we know about the construction of it, etc?”

‘The blunt fact that appears to rise from this is that the LFB hadn’t implemented the coroner’s recommendation’

Andrew Kinnier QC questioned David Brown on behalf of the inquiry (picture: Grenfell Tower Inquiry)

Mr Brown was also asked about an issue that has already come up in this module: the provision of training specifically to address the issue of rapid fire spread in highly insulated buildings.

In March 2015, this issue was brought to the attention of a senior board at the brigade who arranged new training for firefighters.

A report noted: “Rapid fire growth is becoming an increasingly common feature in highly insulated buildings. Studies have shown firefighters are often unprepared for such rapid fire growth and as a result have often not used effective firefighting tactics.

“Compartment fire behaviour training in simulator units has contributed to this lack of preparedness in that the fire in these units rarely extends beyond the compartment of origin.”

This, though, is tricky for the brigade to explain because in 2013, the Lakanal House coroner had specifically instructed them to alter training of incident commanders to increase awareness that compartmentation could, and sometimes did, fail.

On 3 March 2014, the brigade recorded this recommendation as closed.

“The blunt fact that appears to rise from this is that the LFB hadn’t implemented the coroner’s recommendation. Would you accept that proposition?” asked Mr Kinnier.

Mr Brown denied it, saying the “holistic” training and experience of firefighters meant they were well aware of this issue.

The board did place an article in its newsletter to fire stations to alert them about the risk from highly insulated buildings. But this article referred to a building where fire did not break out of the original compartment.

“There could be better examples, yes,” Mr Brown said.

“Ones that involve fire spread outside the compartment of origin, for example?” asked Mr Kinnier.

Training on this issue – as we’ve previously heard – was prepared but not rolled out, as a result of IT issues. Mr Brown said this was essentially that stations did not have the “bandwidth” to run the internet-based training.

“The problem was once we tried to use it, crews were reporting difficulties in terms of buffering at stations and the videos not loading up etc,” he said. “IT were saying to us ‘there’ll be bandwidth improvements, it’s an issue we’re aware of and we’re dealing with it’. It was forever ‘it will be sorted in a month or two’.”

The inquiry has previously concluded that on the night of the Grenfell Tower fire “none of the incident commanders had been able to conceive of the possibility of mass compartmentation failure and the consequent need to consider, and then order, a total evacuation of the building”, at least until assistant commissioner Andrew Roe took over at around 2.30am.

The inquiry is set for a short week next week, with one LFB witness on Wednesday. It will then hear expert evidence on the brigade, starting from Monday 18 October.

Grenfell Tower Inquiry headlines: week 50

LFB training ‘contributed to a lack of preparedness’ for rapid fire spread despite Lakanal warning, inquiry hears

A London Fire Brigade (LFB) document noted that firefighters were often “unprepared” for fires which spread rapidly through buildings and that training had “contributed to [this] lack of preparedness”, a year after it told a coroner it had updated its training in this regard.

Internal LFB report warned of ‘sub-standard’ entries to building database four years before Grenfell

An internal review of a London Fire Brigade (LFB) database of high-risk buildings four years before Grenfell revealed a number of “sub-standard” entries that it linked to a “lack of competency… at all levels of the process”.

LFB did not move to modern model for decision making amid ‘very conservative culture’

The London Fire Brigade (LFB) opted not to move to more modern guidance for incident commanders on decision-making amid a “very conservative” culture that made it “very difficult to implement change”, a former senior officer has told the Grenfell Tower Inquiry.

LFB officer feared pre-Grenfell cladding warning would ‘let the cat out of the bag’

A senior officer in the London Fire Brigade (LFB) feared “letting the cat out of the bag” if it warned housing providers about combustible materials on external walls in the aftermath of a pre-Grenfell tower block fire, the inquiry heard today.

Grenfell Tower Inquiry phase two: weekly diaries

Module one: the refurbishment

Week one: A vivid picture of a broken industry

After a week of damning revelations at the opening of phase two of the Grenfell Tower Inquiry, Peter Apps recaps the key points