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Grenfell Tower Inquiry diary week 55: ‘My review is pretty scathing!’

Insight12.11.213.00 PM by Lucie Heath

In a week that included the 200th day of evidence in phase two of the inquiry, attention turned to the London Fire Brigade’s control room. Lucie Heath reports

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Attention turned to the London Fire Brigade’s control room at the inquiry this week. @luciemheath reports #UKhousing

This week the inquiry focused on the London Fire Brigade’s (LFB) control room, the nerve centre where control room officers (CROs) give advice to emergency callers and pass information onto firefighters.

The focus was largely on the training provided to CROs between 2009 and 2017. Those who have been following the inquiry will know that these are the years between the Lakanal House fire, a high-rise fire that killed six people, and the Grenfell Tower fire, which killed 72.

This is not the first time the inquiry has heard from the control room. During the first phase of the inquiry, which focused on the night of the fire, CROs painted a picture of chaos, with those on shift completely overwhelmed by the unprecedented number of calls they were receiving.

The report into phase one of the inquiry was highly critical of the control room. It noted “serious shortcomings” that “cannot all be attributed to the scale of the incident”.

Some of the key failures highlighted in inquiry chair Sir Martin Moore-Bick’s report were CROs telling callers that firefighters were on their way to them without having a sound basis for doing so, and CROs advising people to stay in their homes despite the caller indicating that they were being directly affected by smoke or fire. The report said these failings were “systemic in nature”.

Many of these criticisms were similar to those laid on the LFB’s control room following the Lakanal House fire in 2009. Sir Martin’s phase one report went as far as to say the LFB’s Lakanal Report was “strikingly prescient” of what would happen at Grenfell.

A key question for the LFB throughout this phase of the inquiry is why so many of the same mistakes were made at Grenfell as were made almost a decade earlier during the Lakanal House fire.

This week, two senior figures within the control room were grilled on this subject.

‘There was nothing showing that control had carried out any form of training’

From Monday until Wednesday this week, Scott Hayward (pictured above), former operations room manager at the LFB, was questioned on the training made available to control room staff.

In 1993 the government wrote to all fire brigades to outline the need to provide “on-watch refresher training to all fire control staff on a systematic basis”. This training should be “scheduled and monitored” with the subject matter depending on identified areas of weakness within a local area.

However, a LFB audit from 2010 on the control training department found that “adequate long-term planning” of training for control room staff was “not being carried out”.

“It is vitally important that adequate training planning systems are implemented for all courses, including appropriate training records that support the cyclical training planning process,” the report said.

Despite this warning, evidence from from the inquiry this week suggested that a well-planned training system was not fully implemented for control room staff in the years leading up to Grenfell.

Notes from a meeting in 2012 showed that a senior officer expressed concerns there was “nothing showing that control [staff] had carried out any form of training”. The officer called for the implementation of a “training matrix” to ensure this was addressed.

Four years later, in July 2016, a “root and branch” review of the control room found that “some staff feel that they are not adequately developed in role”. It said the maintenance of skills training was “ad hoc and not being planned in an appropriate and robust manner”.

Mr Hayward said he agreed in part with that assessment and blamed “competing priorities”, as well as the fact that the control room lacked the technology to have “a more robust system in place”.

‘I feel if we were to take this powerpoint to the Lakanal board, we would be severely criticised’

On Tuesday the inquiry focused specifically on refresher training for fire survival guidance (FSG) calls, which are calls where a CRO stays on the line and gives advice to a person trapped in a burning building.

Following the Lakanal House fire, the LFB agreed with the Lakanal board that it would implement a FSG refresher training programme, the details of which were also sent to the coroner as part of the inquest into the fire.

Starting in 2010, the plan was to implement a programme that would see CFOs given a full day of FSG training every two years and receive computer-based training on FSG calls every other year.

However, the LFB soon began to deviate from the training criteria promised to the Lakanal board. For example, the role-play exercise was changed to a passive exercise, the full day’s training was reduced to half a day, and fire safety officers stopped participating in the training.

From 2012, when the LFB’s training was outsourced to an external company, some staff members were unable to access the computer training, which could not be updated by LFB staff.

Mr Hayward agreed he had been concerned at the time that the Lakanal coroner had been “misled” by the LFB when it came to its FSG training.

It was not only the delivery of the training that was causing concern among some in the LFB. The content of the training also attracted internal criticism.

The inquiry was shown an email from 2011 that was sent by LFB operations manager Joanne Smith, who provided evidence to the inquiry on Thursday, which outlined her “scathing” review of the powerpoint presentations given to staff as part of their FSG training in 2010.

Ms Smith pointed out a number of errors in the slides, including incorrect and contradictory advice for high-rise buildings.

“I feel if we were to take this powerpoint to the Lakanal board, we would be severely criticised. It fails to cover some issues we have already informed the board are dealt with. It is neither positive, grammatically correct and does not emphasise the alternative escape routes.” she wrote at the time.

Mr Hayward told the inquiry that these powerpoints were improved over time, however the inquiry also heard that training became increasingly difficult to deliver due to competing priorities and changes to shift patterns.

Data provided to the inquiry by Mr Hayward showed that 0% of CROs received refresher training in 2015, compared with 94% in 2011. In 2016, 45% of staff received training, while 32% received training in 2017.

While Mr Hayward said he was unsure whether these figures were accurate, which attracted criticism from lead counsel to inquiry Richard Millett QC (pictured above) for the LFB’s poor record-keeping, he did admit that no refresher training was delivered in 2015.

“So as the presentations got better, the system for delivering them got worse,” Mr Millett concluded.

‘A very busy period with significant staffing issues, system problems and restructuring’

When asked to explain the deficiencies within the LFB’s FSG training, one recurrent theme resurfaced constantly throughout the week: the impact of transferring to a new IT system.

In the years leading up to Grenfell, the LFB’s control room was going through the lengthy process of transferring to a new fire engine mobilising system named Vision.

The contract for this system was first awarded in 2012 but issues with the technology meant the system did not go live until 2015. Problems with Vision were still being reported by the media in 2017, just months before the Grenfell fire.

Mr Hayward repeatedly told the inquiry that training became almost entirely focused on transferring to this new IT system. Ms Smith (pictured above) said her work on the system was “all consuming” in 2015 and 2016.

Training was also made difficult by the fact that it was delivered “on watch”, meaning training would have to stop if there was a significant increase in calls.

When asked whether the LFB considered providing FSG training when staff were not on watch, Mr Hayward said it was “discussed” but that there were “cost implications” of releasing staff away from control.

Ms Smith told the inquiry that when she rejoined the LFB from secondment in 2015, the time available for training on things such as FSG had been reduced to accommodate another training programme.

“So the four-hour training slot had moved to a two-hour training slot, which, probably due to the staffing deficiencies as well, made it very hard – unachievable to facilitate all the training in that period,” she said.

Despite the challenges, Ms Smith said she “tried very hard” to roll out FSG training during that period as she was “really conscious… we had committed to training and refresher training every year”.

In his witness statement, Mr Hayward said: “The period between 2009 and 2017 as a whole has been a very busy period with significant staffing issues, system problems and restructuring. During this time there has not been much stability in which to fully take stock of training needs and deliver all of the training that we would have liked staff to receive.”

‘It must be recognised that unprecedented and large-scale emergencies… may occur from time to time in London’

The final major theme covered this week is whether the LFB’s control room could have done more to anticipate and plan for an event on the scale of Grenfell.

On the night of the Lakanal House fire, the LFB’s control room dealt with five concurrent FSG calls – a huge number at the time.

This week we heard multiple examples of training exercises developed by the LFB in the years following Lakanal that involved three or four concurrent calls.

Mr Millett repeatedly asked both witnesses whether anyone had considered after Lakanal that the number of FSG calls could rise above this level, especially given two major fires that took place at Adair Tower and at a Marriott hotel in Poplar during this period. The number of concurrent FSG calls during these incidents is disputed, however some records show that the number exceeded the calls on the night of the Lakanal fire.

Mr Hayward told the inquiry it was not considered after Lakanal that “multiple FSG calls would likely exceed five concurrent FSG calls in relation to a high-rise residential fire”.

On the night of the Grenfell fire, roughly 120 calls were received from occupants of the building. Not all of these would have been FSG calls and not all of them would have been concurrent. However, in his phase one report, inquiry chair Sir Martin Moore-Bick (pictured above) said the number of FSG calls was “wholly unprecedented” and “exceeded by many times the number received in connection with the Lakanal House fire”.

“If lessons are to be learnt for the future, however, it must be recognised that unprecedented and large-scale emergencies demanding a swift and effective response by the fire and rescue services may occur from time to time in London and other major UK cities.

“The circumstances surrounding the fire at Grenfell Tower and the LFB’s response to it should not lead us to think that the unusual scale and speed of smoke and fire spread, the particular nature of the building and the unprecedented number of FSG calls conspired to create challenges that could not be repeated in a different form on another occasion,” the report said.

The Grenfell Tower Inquiry will continue on Monday.

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