Catherine Levin continues her regular column with more analysis of recent developments seen in the Grenfell Tower Inquiry.
From 1 November the Inquiry began to hear more evidence from current and former London Fire Brigade (LFB) senior officers as part of the Inquiry’s investigation into the years leading up to the fire. Firefighters were among other Brigade staff who spoke during phase 1 of the Inquiry and gave some harrowing testimony as they described the response on the night of 14 June 2017.
The LFB is one of the biggest fire and rescue services in the world, with 102 fire stations across the capital serving 9 million people. It has a budget of just under £400m and over 5,000 staff in total. The current Commissioner, Andy Roe, took over in January 2020 after the former Commissioner Dany Cotton retired early. Both attended the Grenfell Tower fire and appeared at the Inquiry during phase 1. The Inquiry is now in phase 2 and during module six on firefighting, both Ms Cotton and Mr Roe made second visits to the Inquiry. Ron Dobson, who was Commissioner from 2007 to 2016, gave evidence for the first time.
On 3 July 2009 a fire broke out on floor 9 of Lakanal House, a 14-floor building in the London Borough of Southwark. The fire spread rapidly to other floors and smoke affected large parts of the building. Six people died. The Inquiry is trying to find out how much the Brigade learned from the 2009 fire and the extent to which it led to change in policy and procedure. It is important context to understand how prepared the Brigade was to respond to the Grenfell Tower fire eight years later.
Commitment to learning
Mr Dobson spoke about his commitment to learning from the Brigade’s response to the Lakanal House fire, when he told the Inquiry that he had established and chaired an oversight board dedicated to this activity. He was Commissioner when the Lakanal House fire coroner sent her Rule 43 letter to the Brigade, setting out five recommendations for improvement.
The March 2013 letter recognised the work that the Brigade had already done in response to the 2009 fire and that included a review of guidance about the handling of fire survival calls and refresher training for officers dealing with these calls. This explains why it was not included as one of her five recommendations.
Fire survival guidance is defined as the advice and guidance given by control room officers to persons who are directly affected by fire, heat, or smoke and cannot leave their premises. I touch on fire survival guidance as it keeps coming up during the Inquiry and it formed a major part of Sir Martin Moore-Bick’s 46 recommendations in his Phase 1 report published two years ago.
The reason for the Inquiry’s interest in fire survival guidance is that on the night of the fire, Brigade control was overwhelmed by the number of callers who were directly affected by the fire and sought fire survival guidance. Ordinarily, control officers would follow fire survival guidance policy to provide advice and reassurance to callers, but this might just be for one caller, maybe two.
The Inquiry is looking at the workings of the control room and explored this from different perspectives, starting with Scott Hayward. Mr Hayward joined LFB in 2006 after a career in the Royal Navy. He was Principal Operations Manager managing the control room functions at the Brigade until he left in July 2019.
In 2011, the Brigade reduced the number of control room staff on duty at any one time from 24 to 16 and counsel wanted to know if there had been any internal discussion about how the Brigade would cope if there were multiple fire survival guidance calls. Mr Hayward could not recall if there was and didn’t know if a risk assessment had been carried out on the changes. This was just two years after the Lakanal House fire.
Joanne Smith worked for Mr Hayward and told the Inquiry that from 2009 she listened to and reviewed fire survival guidance calls that came into the control room. This is something she did voluntarily, and she continued to do this until she was seconded to the Chief Fire Officers Association in 2012. During that period, she said that these calls were associated with 40-50 separate incidents across London. This is significant, because it speaks to the volume of this type of call and how relatively rare they are for the Brigade.
One of the great strengths of this Inquiry is the ability of the legal counsel to explore issues from many perspectives. For fire survival guidance that includes those in Brigade control on the night of the fire, from the control room managers working in the Brigade between 2009 and 2017 and the chain of command above them; it really deserves a report of its own.
The Brigade has spent the years since the Grenfell Tower fire revising policy note 790, which is the guidance for staff carrying out fire survival guidance calls. PN 790 was first introduced in response to the Lakanal House fire, although it is not specifically about calls relating to high-rise fires. A new version of PN 790 was implemented on 31 March 2021.
Expecting the unexpected
During November, former London Fire Commissioner Dany Cotton gave 2.5 days of evidence. Back in September 2018, she was still Commissioner and appeared in her uniform to give six hours of evidence. You may recall the headlines after her session where she responded to this question from lead counsel to the Inquiry, Richard Millett QC. He asked:
‘We’ve been told by senior officers, I think as late as this week, that an operational firefighter would always expect the unexpected. Was this not the unexpected which you should be expecting?’
She responded by telling Mr Millett that she didn’t think it was a reasonable thing to say and that firefighters do expect the unexpected, referring to the terrorist attacks in London in the early part of 2017. She said that they learned from every incident, adding:
‘But in the same manner that I wouldn't develop a training package for a space shuttle to land on the Shard, we would respond to it and deal with it in the same manner we do. That is an incident of that scale, so I wouldn't expect us to be developing training or response to something that simply shouldn't happen.’
Fast forward to November 2021 and Ms Cotton no longer wears a uniform and was much less animated as she gave her evidence second time round. Echoing the question that led to the now infamous quote about space shuttles and the Shard, Mr Millett concluded his questions by asking her: ‘Is it your view that the Grenfell Tower fire was a one-off fire, completely unpredicted, completely unpredictable for which the LFB could never reasonably be prepared?’
Her response backtracks on the certainty with which she answered the question in 2018 and indicates that her view has changed: ‘I still think that even now the knowledge held by LFB and the UK fire and rescue service could not have anticipated such a catastrophic failure of any building with so many breaches. But yes, we did have knowledge of various aspects of that. I think that that has become evident by the documents that I’ve read.’
In 2018, Ms Cotton was asked if there was one aspect to the LFB’s response to the Grenfell Tower fire that she could go back and change. She responded in a confident, strident manner that shocked many. Robert Booth, writing in the Guardian at the time described it as: ‘defensive testimony that angered survivors and the bereaved.’ She said: ‘I wouldn’t change anything we did on the night. I think, without exception, my firefighters, my officers and my control staff performed in a fantastic way given the incredible circumstances they faced. They were put into an untenable situation in a building that behaved in a way it never should have done that put the residents lives at risk.’
Reprising this question in 2021, Mr Millett asked Ms Cotton whether she could identify anything that she could or should have done during her time at the LFB that would have better equipped the incident commanders on the night of 14 June 2017. She is brief in her response: ‘I think that organisationally, there was information we could have shared, that could have been translated into training or members of LFB that may well have assisted them.’
I think this speaks to a theme in Ms Cotton’s evidence, where she shows that while she had leadership roles, she did not have a grasp of the detail. She was in the London Fire Brigade for 32 years and ran the operational assurance department in the years between Lakanal and Grenfell.
Grasp of detail
It was important to grasp the detail of health and safety while in charge of operational assurance and Mr Millett expressed his surprise that she did not have key HSE documents on her desk and wasn’t familiar with them. Referring to the 2010 HSE publication, The management of health and safety in the British fire and rescue service, he asked: ‘Do you accept that you should have been aware of this document, it should have been imprinted on your heart?’ She replied that she had a health and safety professional working for her, and she was dependent on having that professional expertise to hand.
It must be tough to run a huge organisation like the London Fire Brigade and of course leaders can’t be expected to know everything, but the final questions about the HSE reports demonstrate that some detail just needs to be known and it’s part of the job.
Once this module is complete, most likely before Christmas, the Inquiry will move on to hear evidence from government ministers and civil servants. Now that will be interesting.
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Catherine Levin is a Freelance Communications Consultant specialising in fire.