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Grenfell Tower Inquiry diary week 54: ‘Our consideration of evacuation at this time was something of a blind spot’

Insight05.11.213.00 PM by Peter Apps

The development of policy on ‘stay put’, both nationally and for London, occupied the attention of the inquiry this week. Peter Apps reports

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The development of policy on ‘stay put’, both nationally and for London, occupied the attention of the inquiry this week. Pete Apps reports #UKhousing

The Grenfell Tower Inquiry’s examination of the actions of central government began with the development of national firefighting guidance and its impact on London.

It is necessary to begin the report on the week’s evidence with a few explanations.

‘An article of faith… so powerful that to depart from it was unthinkable’

The ‘stay put’ policy is fundamental to the investigation of what happened at Grenfell Tower and why. The inquiry’s first-phase report has already established that it should have been withdrawn at 1.30am at the earliest, or 1.50am at the latest.

As it was, residents continued to be advised to stay in their homes until 2.47am. By this point, smoke had filled the communal staircase and the landings and many of those remaining in the building had lost the chance to flee.

Sir Martin Moore-Bick (pictured above), the inquiry chair, concluded that the primary reason the first incident commander, Michael Dowden, did not evacuate the building was “that he had not been trained for it”. The policy “had become an article of faith within the London Fire Brigade (LFB) so powerful that to depart from it was to all intents and purposes unthinkable”.

This week the inquiry took a deep dive into the development of both national guidance and specific LFB policy on stay put.

‘It will include advice… on evacuation should it become clear during an incident that the “stay put” principle is no longer tenable’

Policy on stay put was contained in two documents. One was Generic Risk Assessment 3.2 (GRA 3.2), published by central government as a direction to local fire services on the risks of high-rise firefighting and what to do to mitigate them.

The second was Policy Number 633 (PN633), an LFB document which was supposed to enact the principles set out in GRA 3.2.

Both of these documents were relatively new at the time of the fire: the version of PN633 in force on the night of the Grenfell Tower fire was published in July 2015, while GRA 3.2 was published in February 2014. This was not a coincidence.

In fact, they had both been reviewed due to the Lakanal House fire in 2009. This fire killed six people, all of whom had been told to stay put in a burning high-rise building. A coroner’s inquest, which reported in March 2013, directed both the LFB and central government to revise guidance on stay put to take account of the risk of rapid fire spread in a high-rise.

The government’s response, sent in May 2013 and signed by then secretary of state Eric Pickles (pictured above) promised “advice to incident commanders to inform decisions on evacuation should it become clear during an incident that the ‘stay put’ principle is no longer tenable”.

How, then, could it have been the case that four years later officers could arrive at an out of control high-rise fire with no training on reversing stay put?

That was ultimately the question the inquiry was exploring this week.

‘I fully acknowledge that our consideration of evacuation at this time was something of a blind spot’

Work to revise GRA 3.2 in the light of the Lakanal House fire had, in fact, begun long before Mr Pickles sent his letter to the coroner.

In March 2011, officials at the Department for Communities and Local Government (DCLG) asked the LFB to carry out this review because they were “best placed” to lead on incorporating the learnings from Lakanal.

This work fell to its then head of operational policy, Peter Cowup (pictured above). The inquiry saw that his original draft, which went out for consultation in February 2012, contained nothing on the need to reverse stay put if a fire spread rapidly. Asked to account for this, Mr Cowup referred to a “blind spot” regarding evacuation.

“I just don’t think we understood, before the Grenfell Tower tragedy... our possible role in evacuation and the need to provide firefighters with specific guidance to deal with it,” he said.

He did say the absence of any “national guidance” on how to actually carry out an evacuation contributed to this.

“In reality, is it blunter than that: that at the time of drafting, neither you nor your team had it in your mind that there may be a need to change stay-put advice?” asked counsel to the inquiry Andrew Kinnier QC.

Mr Cowup said he did not accept this, insisting that reversing stay put was “a clear lesson from Lakanal” and that while the draft was “not as explicit as it could be”, people would have understood from it that there were circumstances when the advice needed to change.

The document was then sent out for national consultation. Gary Brandwick, a senior fire officer from North Wales, responded. He suggested that the sections on evacuation “do not do the necessity for getting the evacuation strategy correct”, adding that brigades “cannot be sure” the building would perform adequately to support a stay-put policy, especially given the lack of sprinklers.

“Now, that’s a sound, legitimate point of view, isn’t it? Did you agree with him?” asked Mr Kinnier.

“I do agree, yes,” replied Mr Cowup. However, Mr Brandwick’s comments were rejected.

Further comments were made when Mr Cowup sent the document out for “proof reading” within the LFB in February 2013.

One officer, Michael Curran, made several suggestions for changes, including the need to consider a “re-evaluation” of advice to trapped callers to stay put “as circumstances change”.

His views were also not taken on board. Mr Cowup explained that, as the document had already been consulted on, he did not feel he could change its substance.

“On reflection, I think [the suggestions] would have added value without a doubt. But at the time I had a rationale for not accepting it,” he said.

With this work complete, Mr Cowup handed the draft over to officials at the DCLG in June 2013.

But the problem was that by now Mr Pickles had sent his letter to the coroner promising clearer guidance on reversing stay put. And this is not what Mr Cowup had provided.

‘Would you agree that this new drafting provides no greater clarity?’

Officials were immediately unhappy with the absence of specific comments in Mr Cowup’s draft on reversing stay put.

Louise Upton emailed internally to say she was “concerned” the document did not deliver on Mr Pickles’ promise to the coroner. “There’s no discussion in this draft of what firefighters can expect residents of flats to do in the event of a fire, and how they should understand when it’s necessary to redirect firefighting resources to mount an evacuation,” she wrote.

Mr Cowup was called in for a meeting at the DCLG in July 2013 and agreed to make amendments to the sections of the draft on evacuations and calls from trapped residents.

He told the inquiry this week that he was “surprised and disappointed” to be asked to make further changes. “I was particularly concerned because we’d had such a challenging time with the national consultation, particularly with the Fire Brigades Union, and I really didn’t want to jeopardise the publication of the document at this late stage,” he said.

Following consultation with colleagues at the LFB, Mr Cowup made some changes and sent the document back to officials in September 2013.

But the changes still contained no express reference to the reversal of stay put when fire spread beyond the flat where it started.

“Would you agree that this new drafting provides no greater clarity on the circumstances in which an incident commander may need to depart from the evacuation plan for a residential building?” asked Mr Kinnier (pictured above).

Mr Cowup argued that while it was “not as expressly articulated as I think it could be”, the new guidance did effectively address the issue of reversing stay put.

However, officials disagreed. One wrote in October that it “does not clearly meet our commitments to the coroner”.

He met government officials again in November, who were still not satisfied that the document met the Lakanal coroner’s requirements.

Mr Cowup said he believed one of these officials, Les Britzman, was “on a bit of a crusade”. “There was almost a ‘look at me’ element to his comments,” he said. “I don’t know whether he was trying to show that he was fighting the good fight.”

Ultimately, the document was published by the DCLG in February 2014 and included new passages introduced unilaterally by the officials.

These included a passage which said “contingency plans” should include: “An operational plan being required in the event the ‘Stay Put’ policy becomes untenable.”

This led to the next major question for this week: why was this not provided for in London?

‘It seems a little surprising, doesn’t it, that that is the one that’s missing?’

A redraft of PN633 had begun long before the new version of GRA 3.2, with a redrafted post-Lakanal version published in November 2011.

This version contained no references to the need to reverse the stay-put policy if a fire got out of control.

However, in April 2013 an LFB officer named Patrick Utting (pictured) was asked to carry out a further redraft to bring it into line with the new version of GRA 3.2, which the LFB was working on with the DCLG. Mr Utting was the week’s second witness.

He said he believed this work would be relatively straightforward: to update the LFB policy to include any missing passages from the national guidance. “I think ‘cut and paste’ rings a bell,” he said when asked how he had been instructed to work.

In August, Mr Cowup emailed him to let him know there would be changes to the document as a result of officials’ concerns. “I wanted him to be aware that there were possibly going to be further changes,” said Mr Cowup.

However, when Mr Utting was shown the final version of PN633, which was ultimately published in June 2015, the section on planning was not the same as the “contingency plans” section of GRA 3.2.

While the list of bullet points was replicated in the LFB document almost word for word, the second one, which required contingency plans to be provided covering the need to reverse stay put, was missing.

“Do you recall whether that was a conscious decision to not replicate the second bullet point in [PN] 633?” asked counsel to the inquiry Hannah Curtain.

“No,” replied Mr Utting.

“It seems a little surprising, doesn’t it, that that is the one that’s missing?” added inquiry chair Sir Martin.

Mr Utting answered by noting that a section on reversing stay put had been included in the section of the document covering evacuation.

This line said: “It may be necessary to undertake a partial or full evacuation in a residential building where a stay-put policy is normally in place.”

This had been added in. It was not included in the initial draft and appeared to be a response to the DCLG changes to the national policy. However, Mr Utting said he could not recall the change being made.

“It seemed to be a little surprising that if you were the master draftsman, with your fingers on the keyboard, you couldn’t remember how something like [this] got into the text?” asked Sir Martin.

“Sir, I spent six years writing policy… and, sir, just the passing of time, and not having been in the loop for the last six years, mea culpa, I’m sorry,” Mr Utting replied.

Following the publication of the policy note, Mr Utting was then required to request new training from Babcock, the LFB’s private training provider, to implement it.

However, his list of points to cover in the training package did not include reversing stay put.

He said he could not recall why this was omitted, but said the request for training was “in its first evolution” and “a starting point” for developing a full training programme.

Mr Cowup was also asked about this gap. “In light of Lakanal… would you agree that it was a fundamental omission not to expressly provide in this document… that incident commanders should be able to know when and how to evacuate a building with a stay-put policy?” asked Mr Kinnier.

“I do indeed accept that,” said Mr Cowup. “The point I was trying to make, perhaps a little bit clumsily, was that there may well have been… considerably more detailed discussion around these quite basic points.”

He referred to the lack of national policy on this point. “Without that national guidance, you would have had to have foresight to develop your own evacuation policy,” he said. “It’s very clear to me now that that was a gap in our portfolio of guidance. At the time, it was not understood. Nobody regrets that more than me.”

In the event, this training package appears never to have been taken forward. Mr Utting’s initial request is where the paper trail begins and ends: there are no further meetings or emails which refer to it being initiated.

“Can I put something bluntly and directly to you: that the reason why no guidance or direction was available in either policies or training was that neither you nor your department had properly considered the impact of [D]CLGs amendments to GRA 3.2 at all?” asked Mr Kinnier.

“I think the people who could answer that best [and] more in an informed way would be the people who drew up the training specification,” said Mr Cowup.

The inquiry continues.

Grenfell Tower Inquiry headlines: week 54

LFB officer unable to explain absence of ‘stay put’ passages from policies he drafted

The officer who drafted London Fire Brigade (LFB) policy on high-rise firefighting has been unable to explain why key passages on reversing ‘stay put’ were omitted from both the policy document and subsequent training.

Lack of specific reference to reversing ‘stay put’ a fundamental omission from training package

A former senior officer at the LFB has accepted that the absence of details of when and how to reverse a stay-put policy during a tower block fire was a “fundamental omission” from its training package.

Government officials introduced lines on revoking stay put to national guidance after LFB omitted them

Government officials were forced to amend national firefighting guidance to include passages on when to abandon ‘stay put’ advice, after the LFB officers who first drafted it omitted any reference to doing so.

LFB did not act on stay put and building safety warnings when it drafted national guidance

The LFB ignored calls to include stronger warnings about building failures and when to revise the ‘stay put’ advice in draft national guidance it prepared for central government following the Lakanal House fire.

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