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Grenfell Tower Inquiry diary week 52: ‘I actually think that there is a measure of incompetence at all levels’

Insight22.10.212.30 PM by Peter Apps and Grainne Cuffe

Expert evidence concluded the current section of the inquiry with some stinging criticism of the London Fire Brigade. Peter Apps and Grainne Cuffe report

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Expert evidence concluded the current section of the inquiry with some stinging criticism of the London Fire Brigade. Peter Apps and Grainne Cuffe report #UKhousing

‘A culture of making do’

On Monday, the inquiry heard from communication systems expert Professor Chris Johnson (above). 

The professor, who produced a report assessing the London Fire Brigade’s (LFB) communication systems on 14 June 2017, gave detailed evidence about the different devices that were used. 

Firefighters tackling the blaze had significant trouble contacting commanders on the ground, with one telling the inquiry last year that the communication equipment was “from the dark ages” and that it was impossible to use radios above the 15th floor because of reception “blind spots” in the tower.  

On the night of the fire, the LFB staff communicated using two devices: the communication sets built into firefighters’ breathing apparatus – known as breathing apparatus radio interface equipment (BARIE) – and hand-held walkie-talkies. 

The signal strength of the one-watt BARIE sets was deliberately limited to reduce the likelihood that the equipment might ignite or blow up, making them what is known as “intrinsically safe”. 

But the weaker the signal, the shorter distance it can reach and the less likely it is to travel through walls.  

The inquiry heard that there was no risk assessment of the higher power radios used on the night. 

Professor Johnson said: “The personal radios that were also provided on the night with the higher power… were used extensively during the fire, and they should have been subject to a risk assessment prior to their use.  

“But I have seen no evidence to suggest that a risk assessment of the sort… was conducted.” 

In a review post-Grenfell, the LFB put the communication issues down to a spike in people using the radios. 

But Professor Johnson, who specialises in the development of safety critical systems, said that the communication technology used was not tested sufficiently to see if it could cope during an incident in a high-rise building. 

He said the communication problems came about as a result of several factors, including blind spots in the building, the power of radio signals and the “sheer number of users” in the area. 

“These different factors, which were all a problem on the night of the fire… placed the firefighters in a very difficult position,” Professor Johnson said. 

He added that it was “remarkable” to him that greater care was not taken by the LFB before and during the fire to “ensure robust and resilient communication between the command units and the bridgehead of major incidents”. 

He concluded that communication failures also stemmed from cultural issues within the LFB, which led to delays in upgrading technology. 

Professor Johnson said in his report that it was his belief that decisions made by LFB in the months and years before the fire “exacerbated delays in replacing ageing… communication infrastructures”. 

“The delays can be explained by a culture of making do and failing to tackle the limitations of existing radio systems in concrete structures,” lead counsel to the inquiry Richard Millett QC read from the report. 

He recommended that ‘safety cases’ – structured arguments about the evidence that should be used to show that a system is acceptably safe – be adopted by fire and rescue services. 

He said the LFB should take a “systemic view” of its communication framework, focusing on the integration and resilience of “multiple infrastructures”. 

He also indicated that this could be a turning point for the LFB to do things better and to have a culture change, recommending that the organisation moves away from a culture of “making do” with legacy information technologies that “increased risks to the public and to their staff” during the Grenfell Tower fire. 

It was also felt that the LFB needed a greater understanding of why so many procurement activities have stalled, making firefighters rely on “obsolete technologies” and why many “innovative” proposals from LFB staff were dismissed. 

“A precondition for change is the acceptance that the LFB should move away from a culture of focusing on device specifications towards resilient and systemic approaches where policy, training and procurement are continually examined in the light of operational experiences, not just from within their own organisation but also from other [fire and rescue services] and from other industries,” Professor Johnson said. 

In response to the findings from phase one of the Grenfell Inquiry, the LFB said it was in the process of replacing and upgrading the radios it used in incidents.  

This would be done in two phases. The first phase will deliver a new type of radio used for both fire-ground and breathing apparatus, which will be more powerful, as well putting in place new training and policy approaches for firefighters. 

The second phase, which is expected to complete in May 2022, will see the delivery of new breathing apparatus that includes improved communication capability. 

‘It’s a pretty basic component to put a fire out, isn’t it?’

Tuesday saw former senior firefighter Steve McGuirk (above) take the witness box. Mr McGuirk has a fairly glittering career in the fire service: 39 years that encompass stints as the leader of Greater Manchester, West Midlands and South Yorkshire – the three largest fire authorities in the country after London.

One of the key questions for this module is whether the LFB erred by not instructing crews to gather information about cladding systems when they carried out inspection visits of potentially risky premises.

Grenfell was subjected to such an inspection before the fire, but nothing was recorded about the cladding and local LFB policy omitted cladding in a list of 22 items to check on these visits, despite it being specified in national guidance. Was this appropriate?

“Cladding systems, certainly insulated buildings and cladding systems, have been a phenomenon affecting firefighting for quite a long time,” said Mr McGuirk. “The phenomenon of buildings being clad… is not something especially new. In fact, it’s had an impact in firefighter fatalities over the years as well.”

The inquiry has already established – in its first phase report – that the information recorded about Grenfell Tower was “woefully inadequate”. There were no plans, an incorrect number of floors and a box titled ‘tactical plan’ left empty and dated 2009.

“Taking a step back, what evidence have you seen that crews were in fact trained on how best to carry out [inspection visits] by the LFB?” asked Mr Kinnier.

“I’ve seen no evidence. Essentially, my sense of it is that the crews may well have been following a much more extensive procedure, but culturally, they did not really see it as being very different to a [prior statutory regime] that they’d already done.”

Asked more generally if compiling this sort of inspection was a “challenge” for authorities around the country, Mr McGuirk agreed that it was. He said this was because of a general “aversion to bureaucracy” among frontline staff, which is “a kind of constant struggle”. This, he said, should have been relieved by “culture and training”.

On training more generally, Mr McGuirk said the LFB training did not equip officers to think on their feet during an incident. He said they “were trained to apply policies and models and that is not the same as being able to develop a tactical plan” – with “conformity to policy being the goal”.

He said training should have encouraged officers to react to unexpected circumstances, and this was particularly key in an era when real-world fires were declining, meaning incident commanders had less opportunity to learn on the job.

Regarding the events of the night, Mr McGuirk had a number of important criticisms of what happened.

One of the first related to water, and the failure to put an officer into the role of ‘bulk media advisor’ (in charge, essentially, of securing the water supply) for the majority of the incident.

This is something that takes on additional significance in the context of another expert’s view that the LFB’s equipment could have sent water to the top of the building with correct water pressure.

As it was, the LFB appears to have been hampered by low water pressure on the night, with one firefighter describing their equipment as akin to a “garden hose”.

“Would discussion of water supplies be a standard topic of discussion in any handover?” asked Andrew Kinnier QC, counsel to the inquiry.

“To be frank, yes. It’s a pretty basic component to put a fire out, isn’t it?” Mr Guirk said.

He also agreed with criticism from the first phase report that the tower should have been evacuated earlier.

He explained that as firefighters at Grenfell were “never going to be able to extinguish the fire”, they should have “prioritised their resources on rescue as well as limiting the extent of the fire spread”.

While he agreed with the difficulties evacuating the building (no alarm, no list of residents and a single staircase compromised with smoke among them) he said doing so was “still preferable to telling occupants to remain in their flats”.

At Grenfell, the decision was not taken to tell people to leave by firefighters at the incident until 2.47am – when the fire had spread to the top of the building and substantially around it.

However, he also noted that there is “no practical guidance in the UK as to how evacuation should be carried out”.

He explained his view that alarms which could be activated by the fire services on arrival to a building would be “extremely effective” in solving this problem in the future.

“Those kinds of systems are already available,” he said. “So you could activate and evacuate a zone, [send] a prerecorded message, etc. These systems are now quite tried and tested, certainly abroad as well as in this country, and I think they’ve got a real part to play in evacuation for the future.”

These alarms were recommended almost two years ago by the first phase report, but have been subject to no push from government since and extremely limited take-up in the sector.

‘Currently, the culture of the London Fire Brigade exhibits, at all levels, a total disregard for technical competency’

After a break on Wednesday, Thursday saw the arrival of the final expert witness of the week: Professor Jose Torero (above).

Professor Torero is a senior civil engineering professor at University College London, and a world renowned expert in fire and disasters, having contributed to reviews of events including the collapse of the World Trade Centre buildings in the 9/11 attacks.

He did not mince his words with regard to the fire service, concluding his report by saying the brigade was “not capable of delivering the role that society expects from it” and requires a “drastic culture change”.

“At the core of this change of culture is transforming the value structure of the organisation to introduce respect and value for technical knowledge,” he wrote.

“Currently, the culture of the London Fire Brigade exhibits, at all levels, a total disregard for technical competency and the understanding of building performance.”

Professor Torero’s witness evidence was couched in technical language and was at times quite difficult to follow.

But he echoed Mr McGuirk’s comments that a ‘dynamic risk assessment’ would have assisted the LFB’s incident commanders into realising the tower should have been evacuated sooner.

“Many decisions that were made or not made misjudged the nature of the event,” he said in his report. Commanders failed to obtain information from 999 calls and firefighters inside the tower to understand how the blaze was behaving.

Why did they not seek this information? “It’s very difficult to try to rebuild what was on people’s minds, but I do believe that what you get from listening to the evidence that they provided is that there was a very, very strong sense of having lost control over the situation,” he said.

“They couldn’t find the necessary reasoning to be able to depart from the plan execution mode in which they were from the beginning.”

In his report, he said “the core of these failings is a profound misunderstanding of risk within modern buildings”. He explained that he based this on repeated statements that the “building should not behave like that” from firefighters.

“What you’re [really] saying is the building for which I was trained to come and fight the fire was a building that didn’t have a fire like this one,” he said.

“But that doesn’t mean that this event was not foreseeable. Given the technologies that we’re using right now in the built environment we had plenty of evidence that it was foreseeable.”

Professor Torero had a more general criticism of the UK’s reliance on ‘stay put’ in the years before Grenfell - which he said was justified with reference to figures which showed of 8,000 fires in high rises just 22 resulted in an evacuation of more than five people.

These figures appeared in a government-endorsed guide published in 2011, which was highly influential in the social housing sector and has been discussed at the inquiry several times before. The guide encouraged a strong reliance on stay put.

But Professor Torero said this misunderstood the risk of a fire where compartmentation failed. “The reality is a risk is always defined by the probability multiplied by the consequence,” he said.

Even if the probability of a fire like Grenfell was low, the consequences were “massive”, he said. This meant it should have been planned for.

He said the figures were also selective - recording only whether a stay put policy was implemented not whether it should have been. The result is, it did not record any “near misses”.

“The way in which we collect the statistics defines the way in which we think, and unfortunately, because we are not collecting the near−misses, we [were] missing all these cases where we had all the alarm bells and all the warnings that were telling us that we were going in a certain direction,” he said.

He said that decisions which require “investment” and “effort” were not taken were avoided because of the comfort taken from these statistics.

“People use the fact that we have declining fire events, we have declining fire deaths, just basically to support all our practices,” he said. “It’s not only the fire brigades, but it is the way in which we design, the documents that we use, the policies that we implement − everything is backed by the fact: it’s not going to happen to me.”

Certainly, the government in the years before Grenfell placed emphasis on falling fire deaths to justify not taking stronger action to prevent a disaster.

Professor Torero said: “What was missed is the consideration that building fabric was changing… Given the date of this refurbishment and everything that had happened in the past 10 years, I actually think that there is a measure of incompetence at all levels.”

His evidence concludes the fifth module, which examined the actions of the LFB in the years before the fire.

What’s next?

The inquiry will now hear closing statements for module three – which covered the management of the building – before it finally begins its mammoth section looking into the role of central government.

This will start with an examination of the role of government in relation to the fire services, making it a neat addendum to the current evidence.

It will then have three further parts: testing and certification of materials, fire risk assessments and the role of central government generally.

Grenfell Tower Inquiry: week 52 headlines

LFB ‘not capable of delivering service society expects’, says expert

The London Fire Brigade (LFB) is “not capable of delivering the role that society expects from it”, exhibits “total disregard for technical competency” and requires a “drastic change of culture”, an expert has said in his report to the Grenfell Tower Inquiry.

LFB did not place anyone in charge of water supply until it was ‘too late’, says expert

A firefighting expert has criticised the London Fire Brigade’s (LFB) failure to put an officer in charge of water supplies during the Grenfell Tower fire.

Culture of ‘making do’ at LFB contributed to communication problems at Grenfell, says expert

A culture of “making do” fed into communication problems faced by the London Fire Brigade (LFB) on the night of the Grenfell Tower fire, according to a communication systems expert.

Grenfell Tower Inquiry phase two: weekly diaries

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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